Institute for the Study of International Migration

Center for Contemporary Arab Studies

Urban in Elżbieta M. Goździak and Alissa Walter Georgetown University

Photo: René de Cock Acknowledgements This research was conducted with the generous financial support of the Bureau of Population, Refugees and Migration (BPRM) in the U.S. Department of State. We are grateful to Ms. Sarah Cross, our project officer at BPRM, for her dedication to this project. Our heartfelt appreciation goes to our team members on the ground in Cairo, particularly Dr. Ray Jureidini and Ms. Emilie Minnick, as well as our research assistants who wish to remain anonymous. We would not have been able to complete this project without you. Many thanks to the staff members of UNHCR, BPRM and UNHCR implementing partners, and other service providers who gave generously of their time and knowledge. We wish to express our admiration to for all the refugees in Cairo whose experiences of displacement and coping with formidable challenges are inspiring. Thank you for sharing your stories! And last but not least, we want to thank each other and our copy-editor extraordinaire Nina Laufbahn. Table of Contents Executive Summary 4 Chapter 1: Setting the Scene 5 1.1 Refugees in 5 1.2 The Study 6 1.3 Methodology 6 1.4 Organization of the Report 9 Chapter 2: Legal and Policy Frameworks 10 2.1 The Evolution of UNHCR-Egypt’s Policy on Urban Refugees 10 2.2 Legal and Policy Frameworks for Refugees 10 2.3 Legal Frameworks for Human Rights Protection 12 2.4 Trends in Durable Solutions 13 2.5 Protection Threats: Before the Revolution 14 2.5 Protection Threats: After the Revolution 14 2.6 Recommendations 16 Chapter 3: Refugee Livelihoods 17 3.1 Access to Employment 17 3.2 Vulnerability of Domestic Workers 18 3.3 Financial Assets: Savings and Remittances 19 3.4 Cash Assistance 19 3.4 Housing Costs and Living 20 3.6 Recommendations 22 Chapter 4: Education 25 4.1 Access to Primary Education 25 4.2 Access to Secondary Education 27 4.3 Access to Higher Education 27 4.4 Recommendations 28 Chapter 5: Access to Quality Affordable Healthcare 30 5.1 Health Insurance 30 5.2 Healthcare Services 30 5.3 Health Issues 32 5.4 The Effects of the Revolution on Refugees’ Health and Well Being 35 5.5 Access to Healthcare 35 5.6 Efforts to Mainstream Refugee Healthcare 36 5.7 Recommendations 37 Chapter 6: Conclusions 39 References 40 Executive Summary 1997 Policy Statement Areas, inUrban onRefugees which respond to refugees’ needs. Onemajorinitiative was UNHCR’s UNHCR hasadopted variousstrategies over theyears to better and security, livelihoods, education, andhealthcare. remain for theserefugees intheareas oflegalprotection various refugee populations inCairo, numerous challenges (NGOs) to provide protection andassistance for these Egypt, and numerous non-governmental organizations GovernmentDespite themany ofUNHCR,the efforts of offering protection, andfacilitating durable solutions. institution responsible for determining refugees’ status, CommissionerHigh for (UNHCR) is the primary Refugees society. For alloftheserefugees, theUnited Nations anewlife by integratingof origin, orstart into Egyptian resettlement,country eventually return to theircountries and elsewhere have fled to Cairo hoping to findthird- of refugees from Sudan,Iraq, Ethiopia, Eritrea, Palestine refugeesof urban in the world. recent In decades, waves Cairo, Egypt ishometo oneofthelargest populations • • Legal recommendations: makesthefollowingBased onthisdata, thisreport providers. refugee service the mainNGO-based based organizations. These stakeholders represent international NGOs, Egyptian NGOs, andlocalcommunity- with 16stakeholdersinCairo, includingwithUNHCR, addition,ourteam extensive conducted In interviews and analyzed by our research team in Washington, DC. were to accessability Interviews translated basic services. of the revolution and about the impact on their security 2011wereRevolution askedadditionalquestions inJanuary and health;respondents theEgyptian after interviewed present experiences withsafety, livelihoods, education, were questions about their past and asked open-ended allhouseholdinterviews.member conducted Households team by anon-the-ground assistants trained andsupervised Egyptian households. or local Egyptian Refugee research 22 percent African refugee households, 32percent local target populations: 49 per cent refugee Iraqi households, team 63householdinterviews, conducted distributed across between December 2010andMarch research 2011.Our refugee andlocalEgyptian populations, inCairo conducted withboth studyisbasedonhouseholdinterviews Our gaps ofCairo’s many different refugee populations. analysis ofthediffering needs, experiences, andprotection a comparative while undertaking the new 2009 policy seeks to of provide evaluation oftheimpact apreliminary refugees into national institutionswhenpossible. This report protection for refugees incitiesandat mainstreaming refugees onurban aimedat increasingissued anewpolicy stressed self-reliance for refugees. urban 2009,UNHCR In Train law enforcement aboutrefugee rights and theGovernment ofEgypt the1954MOUbetween UNHCR-Egypt Re-negotiate Executive Summary 4 • • • • • • • Livelihoods • • • • • • • • Health • • • • • • • Education Expand economic development programs Address negative economic strategies Track theemployment ofrefugees microcredit enterprises Work withtheEgyptian government to allow developers withinrefugee NGOs Create roles for employment advocates andjob programs Build protective elements into economic refugee right to work to allrefugees Advocate withtheGovernment ofEgypt to the extend andorganizations networks community Provide additionaltraining for refugee andlocal cultural sensitivity Train and inanti-discrimination implementing partners Sudanese refugees withclosedcases Re-interview Reformulate systems ofmental healthcare for refugees Decentralize refugee healthcare system Mainstream refugees into theEgyptian healthcare healthcare for Iraqis andtertiary fund for secondary Partner withtheGovernment to ofIraq form aspecial refugees Create asubsidized healthcare insurance planfor refugees Provide additionaleducational training for adult Involve UNICEF forcapacity refugees andEgyptians alike Build additionalschoolsto increase educational local schools Involve educated refugee adultsto of enhance capacity administrators, aswell asfor refugee teachers Provide training for Egyptian teachers and inEgyptian publicschools Build capacity Streamline schooladmissionrequirements Chapter 1: Setting the Scene

More than half the refugees the United Nations High in Cairo, Iraqi refugees’ social and educational backgrounds Commissioner for Refugees (UNHCR) serves now live in urban continue to set them apart from other refugees in Egypt. areas. Egypt is among the top five countries with the largest In this report we focus on Iraqi refugees’ access to legal number of urban refugees in the world and is one of only two protection, livelihoods, education and healthcare. We African countries that do not mandate that refugees reside contrast their situation with the circumstances of other in camps (Sperl 2001; Zohry 2005). The majority of refugees refugees settled in Cairo as well as with the situation of in Egypt live in the capital city of Cairo (Grabska 2005). the local population residing in the same neighborhoods. UNHCR developed its first Policy Statement on Refugees in Many of these refugee groups share the same unsustainability Urban Areas in 1997, mainly to discourage urban settlement of their current lives in Cairo, as durable solutions have been due to the difficulties of protecting and supporting elusive for many refugees. Many refugee populations have refugee populations in cities. At the time the 1997 Urban lived in Egypt for more than five years without “immediate Policy was written, UNHCR was struggling to adequately prospects for implementation of durable solutions,” thus respond to situations when refugees abandoned rural constituting a “protracted” refugee crisis based on UNHCR camps and moved to cities, where they often lived in the criteria (UNHCR 2009a). The prolonged stay in Cairo poorest neighborhoods, took menial jobs in the informal endured by many refugees further indicates that neither economy in order to survive and were frequently arrested resettlement nor repatriation are viable durable solutions CH1: or mistreated by the local authorities or attacked by the for many of Cairo’s refugees. At the same time, refugees’ the Scene Setting host population (Chatelard 2011: 9). By and large, however, long-term residence in Cairo does not necessarily indicate UNHCR’s 1997 Urban Policy did not deter refugees from successful integration. Local integration is understood moving to cities. Furthermore, its emphasis on self-reliance to have three basic components: legal, economic and did not adequately address the needs of urban refugees socio-cultural. Legally, integration may be achieved when in countries like Egypt, where refugees do not have the refugees acquire a sufficient amount of rights in their host right to work. As early as 2001, researchers like Sperl noted state to access the jobs, healthcare and education they need the detrimental effect the 1997 policy had on refugees in to be self-sufficient. Economically, integration is achieved Cairo, who were simultaneously urged by UNHCR-Egypt to when refugees live at approximately the same standard of become self-sufficient and barred from legal employment living as members of their host community. Socially and by the Government of Egypt. The result, in Sperl’s words, was culturally, refugees have integrated when they participate in often “destitution.” In response to the various shortcomings the community life of their host country on an equal basis of the 1997 policy in Egypt and elsewhere, UNHCR issued as host country nationals (Fielden 2008). By these measures, a new policy on urban refugees in 2009. In this new policy, few refugees in Egypt have successfully integrated: UNHCR argued that cities are a legitimate place of refuge they lack access to the formal labor market, nearly all for those seeking asylum and committed itself to providing seek health and educational services outside of local protection to refugees in urban areas. This new policy Egyptian institutions and many suffer from discrimination. shifted its emphasis from self-reliance to mainstreaming refugees into local institutions, noting the cost and ultimate UNHCR-Egypt’s refugee services attempt to ameliorate inability to sustain parallel, refugee-specific services. the integration challenges refugees face, but may also inadvertently contribute to refugees’ separation from Our research team began fieldwork in Cairo in December mainstream Egyptian society by creating parallel refugee- 2010, which was a key moment of transition for both UNHCR- specific systems of care. UNHCR-Egypt and its implementing Egypt and, on the eve of revolution, for the country as a partners have developed a wide range of programs to whole. Our field data, collected between December 2010 and meet the diverse needs of their refugee clients. While these March 2011, captures both the lingering ill effects of the old services have undoubtedly been essential for many refugees 1997 policy and the promise of new beginnings under a new in procuring livelihood support and accessing healthcare 2009 UNHCR policy as well as a new Egyptian government. and educational services, the support system as it stands shows signs of strain in the face of a large and heterogeneous Cairo is currently hosting large numbers of refugees refugee population dispersed throughout Cairo and vicinity. from Iraq, Sudan, Somalia, Ethiopia, Eritrea, Palestine and Moreover, UNHCR’s 2009 Policy on Urban Refugees also elsewhere. Each refugee group in Egypt has a unique profile points to the cost and ultimate inability to sustain parallel, based on its legal rights, wealth, education level, languages refugee-specific health and educational programs outside spoken, length of time in Egypt and prospects for durable of mainstream local institutions. The strain of maintaining solutions. We will explore these complexities and their parallel refugee systems is particularly evident in Egypt. At implications in greater depth below. In this report we focus the same time, any long-term solution put forth by UNHCR- primarily on the Iraqi refugees residing in Cairo, Egypt, Egypt and its partners needs to take into account the fact that whose situation is often quite distinct from that of African Egyptian health and educational services are overstretched, refugees in Cairo. Iraq is a middle-income, oil-producing poorly funded and often of low quality, and that many country whose citizens at one time enjoyed quality social, also suffer from the same conditions of poverty and educational and healthcare services. When Iraqi refugees high rates of unemployment as do refugees. UNHCR-Egypt began arriving in Cairo after 2003, many came from middle- has taken some promising steps towards mainstreaming class communities, were well-educated and had adequate aspects of refugee health services, particularly during financial resources to cover their costs of living. While these and immediately after the 2011 Egyptian revolution. Our resources in many cases are running out after years of living

5 research revealed new short- and long-term strategies for that the shift to mainstreaming must be accompanied by continuing this mainstreaming trend in order to improve the investment of development aid into improving and refugees’ access to essential services, increase protection, expanding Egyptian healthcare and educational institutions enhance prospects for local integration and reduce the for the benefits of both refugees and the local population. burden on current refugee-specific service providers. The necessity of this shift is all the more clear in a city The results of this study confirm conclusions other researchers like Cairo, where a relatively weak civil society and have made over the past decade (Sperl 2001; Grabska 2006, resulting paucity of viable community-based partners 2008; Kagan 2011); namely the best way forward is to has hindered UNHCR-Egypt’s efforts to create a robust shift away from short-term programs and parallel service and sustainable system of refugee-specific services. In delivery systems towards the practice of mainstreaming the ten years since Sperl’s study, the overall number of refugees into Egyptian institutions and according them refugees in Cairo has increased considerably and the rights enjoyed by Egyptian citizens, including the right economic situation has worsened, further taxing refugee to work. As recommendations to mainstream refugees in services offered by non-governmental organizations. The Egypt have been made for over 10 years with little progress Egyptian revolution has negatively impacted the Egyptian made, we are cognizant of the practical barriers and political economy and security situation, worsening the living realities in Egypt that have made implementation of these conditions of Egyptians and refugees alike. Faced with recommendations difficult. As our research indicates, these daunting conditions, UNHCR-Egypt will benefit from however, the current system of refugee-specific services is increased burden sharing with Egyptian institutions and inadequate in many respects and expensive to maintain, better strategies to integrate refugees into local society. and as such, drastic changes must be made. We argue 1.1 Refugees in Egypt The modern state of Egypt received multiple waves of concern to UNHCR but who are not eligible for resettlement. refugee populations throughout the twentieth and the There are unknown numbers of Sudanese with closed files.

Setting the Scene beginning of the twenty-first century. We will provide a brief overview of each refugee population in chronological Egypt and Sudan have deep historical ties and a certain CH1: order as a way to provide a brief overview of the fluctuations amount of cross-border migration and trade has always in Egypt’s refugee policies over the years and the impact existed. Migration flows increased dramatically during of these policies on refugees residing in Egypt today. the years of the Sudanese Civil War and crisis in Darfur, which sent thousands of Sudanese to Egypt as refugees. Palestinian Refugees These refugees underwent individual Refugee Status Determination (RSD) with UNHCR-Egypt in Cairo, and not Egypt has hosted Palestinian refugees since as early as all were officially recognized. Many of those with closed 1948; UNHCR estimates that as many as 70,000 Palestinians files remained in Egypt, however. Those who have closed live in Egypt currently (2010). Initially, the Government cases do not have the protection of UNHCR as refugees of Egypt extended numerous rights and privileges to and are not eligible to access a number of refugee-specific Palestinians, permitting them to attend public schools and services offered through NGOs. In 2004, the Governments access state institutions on the same basis as nationals. This of Egypt and Sudan signed the Four Freedoms bilateral policy changed in the mid-1970s, following a breakdown agreement, which granted Sudanese the rights of work in relations between the Egyptian government and the and residency. Since 2004, Sudanese asylum-seekers have Palestinian Liberation Organization (PLO) (Shiblak 1996; been granted temporary protection status by UNHCR- El-Abed 2005). Since this time, Palestinians have been Egypt, but UNHCR-Egypt no longer undergoes RSD with prohibited from attending public schools or utilizing other Sudanese refugees. This “temporary protection” was state services. Palestinians must pay foreigner tuition fees for supposed to last for 6 months, but the Government of private schools and universities. Furthermore, Palestinians Egypt has extended it until today, though without clarifying are typically not eligible for refugee-specific services. The what status Sudanese refugees may eventually hold long- United Nations Relief and Works Administration (UNRWA) term. This temporary protection status qualifies them for does not operate in Egypt. UNHCR-Egypt has identified certain NGO services; however, temporary protection status 70,000 Palestinians in Egypt as Persons of Concern, but disqualifies Sudanese from international resettlement. In assists only 30 of them (UNHCR 2010a). Thus Palestinians recent years, UNHCR-Egypt has begun to practice RSD with have no official protection space within Egypt. In response, Darfurians and Northern Sudanese, and these recognized Palestinians have developed a number of community- refugees would potentially be eligible for resettlement based institutions, including schools and clinics, to (Kagan 2011). The complexities of the RSD process for the provide for the needs of their refugee community. Most Sudanese population in Egypt, combined with low rates of Palestinians in Egypt live far below the poverty line, resettlement, has resulted in tension and misunderstandings though there are some wealthy members and benefactors between the Sudanese and UNHCR-Egypt over the past within the refugee community in Cairo (El-Abed 2009: 80) decade, which has periodically flared up into protests and violence. As recently as April 2011, UNHCR-Egypt has re- Sudanese Refugees committed itself to increasing the use of third-country The largest refugee population in Cairo is the Sudanese, with resettlement for refugees in Egypt, including the Sudanese. approximately 10,300 registered refugees and an additional 14,500 asylum seekers currently in Egypt (UNHCR 2012)— East African Refugees the latter number indicating those who are persons of A number of refugees from other countries also live in 6 Cairo. Approximately 8,000 Somali refugees and asylum experiences of urban refugees in Cairo, the experiences seekers have established themselves in Egypt, along with of refugees in the Sinai will not be considered here. 1,300 Eritreans and a few hundred registered Ethiopians (UNHCR 2012). Somalis are granted refugee status on a Iraqi Refugees prima facie basis. In contrast, Ethiopians and Eritreans Egypt also hosts a large number of Iraqis: currently 7,400 have must go through the RSD process, and the acceptance refugee status in Egypt (UNHCR 2012). Most Iraqis arrived in rate for these communities has been as low as 20 per cent Egypt between 2006-2007. The Iraqis are distinguished from in some years, which explain the disparities in numbers of other refugee populations in Cairo by their previous wealth Books Books registered refugees between these communities. Scholars and education. Upon arrival, 31 per cent of Iraqis reported estimate that there may be thousands of unregistered they had a “very good” financial situation, while 51.4 per refugees—Ethiopians, in particular—living in Cairo. These cent reported a “sufficient” amount of financial resources migrants are usually living without a recognized legal to cover basic needs (WHO and MOH 2009). A number of status in Egypt, which can contribute to a profound sense Iraqis receive remittances from relatives in Iraq. At the same of instability, vulnerability and fear. According to scholar time, the wealth and well-being of the Iraqi population has Fabienne Le Houerou, many unregistered Ethiopians are deteriorated over time—now only 4.7 per cent reported a young men who deserted the Ethiopian and Eritrean armies “very good” financial situation, and 56 per cent reported a and potentially face the death penalty if they return. Prior decline in their health and nutrition (WHO and MOH 2009). to 2004, few Ethiopians received refugee status, in part due Although Iraqis speak Arabic and do not tend to suffer from to a lack of understanding among the Ethiopian community racial discrimination in Cairo, Iraqis reported to our research about the RSD process. Since 2004, a legal aid organization team that they did not have close relations with the local CH1: has assisted with RSD applications and interviews, resulting

host community. Iraqis also reported that they lacked a the Scene Setting in much higher acceptance rates (Le Houerou 2006). sense of cohesion and community with other Iraqi refugees Though Cairo was once the primary destination for East in Egypt. Unlike the Sudanese, they have few community- African migrants, in recent years increasing numbers based organizations (CBOs) or institutions because President have attempted to pass through the Mubarak’s administration repeatedly refused to accept into Israel. The authors recognize the grave protection any applications to form Iraqi CBOs. All Iraqis interviewed risks that migrants and refugees along the Israeli expressed a strong preference for resettlement in a third border face. However as this report focuses on the country; none accepted staying in Egypt indefinitely. 1.2 The Study This report is part of a larger, comparative study on Iraqi urban their situation not only in relationship to protection refugees in Cairo, Egypt and , Jordan (see Martin and principles as enunciated in the Refugee Convention, but also Taylor 2012; Davis 2012). This study focused on the most in comparison with similarly situated local populations and politically complex set of challenges, namely incorporating other refugees living in the same urban neighborhoods. In refugees into existing urban structures that deliver healthcare, Cairo, there are significant populations of Sudanese, Somali, education, child welfare and other forms of assistance to Ethiopian, Eritrean and Palestinian refugees with whom the poor while also facilitating access to employment. we have compared the Iraqi refugees. These comparisons have been illuminating not only in understanding the While Cairo’s urban refugees, including Iraqis, have received situation of the Iraqi refugees, but also in identifying research attention in the past, most studies focused on a more precisely the public reaction to the refugees and single refugee group. This study provides a comparative the context in which decisions are made on their future. perspective on Iraqi urban refugees in Cairo that investigates 1.3 Methodology Seeking both depth and breadth of understanding of the Principal researchers and research assistants from all three of studied issues and affected populations, we designed these institutions took part in identifying and interviewing our study to have both a “top-down” and “bottom-up” government officials, international and local NGOs, and approach, interviewing both stakeholders and refugees in CBOs in Cairo. For interviews with refugees, we relied on a order to gain a comprehensive picture of the lives of urban Community-Based Participatory Research methodology, refugees in Cairo and their ability to access educational whereby our team trained refugees to conduct interviews and health services and provide for their families. We within their own communities.1 Our refugee assistants were assembled a research team that was well-suited to gain recommended to us by our colleagues at the American access and insights from our various research subjects. For University in Cairo and by NGO service providers. These stakeholder interviews, we formed a collaborative team assistants used snowball sampling to identify their research between Georgetown University’s Institute for the Study of subjects, targeting neighborhoods where large numbers International Migration, Georgetown University’s Center for of refugees lived.2 We instructed our assistants to be sure Contemporary Studies and the American University in Cairo. to interview a wide range of households, with varying 1 Community-Based Participatory Research is a methodology that has been highly praised by researchers in a number of fields. This methodology not only engages with members of the studied community as “equal partners,” but also often allows for more rigorous research by gaining the investment and cooperation of research subjects in the study. Researchers scrutinizing this methodology have found that Community-Based Participatory Research often increases both the quantity and the quality of the data collected (see: Viswa- nathan et al. 2004). 2 These neighborhoods included: 6th of October, Heliopolis, Maadi, Arba’ wa Nuss and Ard al-Liwa. 6 7 Books perspective Ofthese 16 3 emic understanding is emic ata Analysis D Data Collection: Stakeholder InterviewsStakeholder Eligibility requirements for services for Eligibility requirements services access to refugees Barriers by faced in groups refugee between Differences servicesaccessing refugees in locals and between Differences servicesaccessing in seeking refugees Barriers by faced employment Impact of Iraqis on health services, educational services, of living the labor market and cost in groups refugees between Differences with UNHCR-Egypt registering to the local benefits and burdens The community in hosting Iraqi refugees to the local benefits and burdens The community in hosting other refugees • • • • • • • • • open-ended interviews. The ethnographic process offered offered process ethnographic The open-ended interviews. take the lead them to encouraging dignity by the refugees narrate able to were They in the interviews if they so chose. highlighting words, in their own experiences their own important. not consider may “experts” issues that the insiders’ Interviews provider also stakeholders with perspectives on the challenges and opportunities involved in Cairo. residing in meeting the needs of urban refugees In principles of keeping with the methodological The qualitative research approach used in this project offered projectthis in used offered approach research qualitative The interviews us to enabled Ethnographic advantages. many an see the phenomenon under study from The of view.” point “insider’s or the sources of different close exploration through developed including participantof data, observation and in-depth, Arabic speaking refugees were provided to the research the research to provided speaking were Arabic refugees research graduate two by and translated in Arabic team Studies Arab Contemporary for the Center from assistants interviews in from Notes University. Georgetown at English. in rendered were other than Arabic languages of a top-downhalf of our study consisted second The met with key service our team wherein providers approach conducted in-depth interviews We working with refugees. the covering service providers of 16 different with a total aid legal (7), programs psychosocial (6), health of fields educational other (6), schools and training (5), vocational (3). rights (4), human and refugee programs a variety met with our team of different organizations, (3); organizations typesinternational of stakeholders: (7), Egyptian NGOs International NGOS (2), Egyptian school (1), and a private health institutions (2), Egyptian 16 organizations These (1). Organization Based Community the main NGO-based service refugee providers. represent with stakeholders included the following Issues explored questions: Individual interviews lasted anywhere from one to two two one to Individual from interviewsanywhere lasted conducted the in were exceptions few and with hours interviews with from Notes languages. native refugees’ 8 Data Collection: ocio-demographic characteristics and in the city Interactions with UNHCR-Egypt Experiences with the education system with the education Experiences services with other Experiences in the area the future Goals for local Relations with other Iraqi refugees, and other refugees populations of security in their neighborhood Perceptions The Iraqi communityThe of origin historyMigration and living conditions Livelihoods Self-reported and experiences health status system with the healthcare S Household and Individual InterviewsHousehold and Individual • • • • • • • • • • •

Several organizations provide more than one service, so the numbers add up to 31, rather than 16. than one service, 31, rather so the numbers add up to more provide organizations Several reliable indications of changing perceptions of security. of security. perceptions of changing indications reliable 3 were able to ask these questions in the immediate aftermath ask these questions in the immediate able to were and memories of our the experiences of the revolution, their testimonies consider We “fresh.” very were respondents how refugees and Egyptians perceived their safety and their safety perceived and Egyptians refugees how of protests during the 18 days security the revolution, prior to in January 2011 and after the fall of Mubarak. Because we safety and perceptions of security and local of refugees and perceptions safety in January Beginning added additional populations. 2011, we our household interviewquestions to determine guides to perceptions of security among both refugee and Egyptian of security and Egyptian among both refugee perceptions 2010, prior During in December our fieldwork populations. questions about asked general our teams revolution, the to The Egyptian revolution began midway through our data our data through midway began revolution Egyptian The gage changing positioned to well were collection. such, we As ended questions were asked and intensive participant intensive and asked were questions ended observation also carried was In out. of this the course including: of issues, a wide array explored have study we our sample size does not allow for quantitative analysis. quantitative for does not allow our sample size but were a discussion guide interviewsThe followed a close-endednot restricted by Open- questionnaire. in identifying key neighborhoods and populations so key neighborhoods and populations in identifying and trends to patterns our summarythat relate findings However, in Cairo. populations among the urban refugee discussions with refugees in settings in which they naturally naturally in settings in which they discussions with refugees we is small, sample size the total Although congregate. strategic be sufficiently to able were we that confident are Ethiopians, Somalis and Palestinians. Additionally, we we Additionally, Somalis and Palestinians. Ethiopians, Our conducted 20 interviews households. Egyptian with group and informal groups also conducted focus team with refugees and local populations. Following our Following and local populations. with refugees plan, these included 31 interviews with research original Iraqi households and 14 interviews households with including Sudanese, populations, among other refugee The project included a total of 63 household interviews of 63 household project included a total The with significant refugee populations living nearby. living populations refugee with significant backgrounds, livelihood opportunities and ages. We also also We opportunities livelihood ages. and backgrounds, conduct to similar assistant research an Egyptian hired interviews living in neighborhoods families with Egyptian income levels, refugee registration statuses, educational educational statuses, registration refugee levels, income

CH1: Setting the Scene the Setting ethnography, analysis commenced within a short period review process were managed and analyzed using NVivo, a after the first set of interviews was conducted. Having computer software used to manage and analyze text-based local researchers and refugee research assistants on the data (Bazeley 2007). NVivo was instrumental in conducting ground allowed us to go back to the interviewed refugees both “interpretive” (making sense of research participants’ when we needed more information or were unsure of our accounts) and “reflexive” (the research team’s contribution interpretation. Collected data as well as peer-reviewed to the data creation and analysis process) analysis. papers and gray literature identified during the literature 1.4 Organization of the Report Our report is organized around four main topics: legal policies and protection space, livelihoods, education, and health. In each of these four sections, we compare the relative ease or obstacles encountered by different refugee populations in accessing essential services. Each section includes policy and programmatic recommendations. The executive summary that opens the report provides an overview of the study and summarizes our recommendations. CH1: the Scene Setting

9 Chapter 2: Legal and CH3:

Policy Frameworks Livelihoods Refugee

IRefugees who spend any length of time in Cairo face result, security and access to services for refugees are often numerous obstacles to meeting their basic needs due to the jeopardizeds. UNHCR’s 2009 urban policy responds to the highly restrictive legal environment in which they live and limited legal protection of urban refugees everywhere by

receive services. Protection space varies between different expanding UNHCR’s protection mandate to refugees in cities Refugee Livelihoods refugee populations, as Egyptian laws distinguish between (2009b). Over the past ten years, the Government of Egypt

refugees of different national origins. Furthermore, protection and UNHCR-Egypt have taken different steps to expand CH3: space appears to have shrunk in recent years: stakeholders’ their protection of urban refugees, which will be explored budgets have constricted, numbers of urban refugees below. Even with this laudable expansion of selected remain high and the Egyptian Revolution and its aftermath rights for select groups of refugees, these rights remain continue to contribute to an unstable environment. As a largely limited in practice and are rarely fully implemented. 2.1 The Evolution of UNHCR-Egypt’s Policy on Urban Refugees UNHCR first promulgated policies regarding protection and urban areas, writing new procedures for registration and assistance for urban refugees in 1997. This policy reflected data collection, ensuring documentation, creating more a growing trend among refugees seeking livelihoods and efficient refugee status determination processes, engaging services outside of UNHCR-supervised camps. The primary in community outreach, fostering more constructive objectives of the 1997 policy were to foster local integration relationships with urban refugees, ensuring greater security, and to promote self-reliance among urban refugees. promoting livelihoods and greater self-reliance, expanding access to healthcare, education and social services, In 1999, UNHCR’s Evaluation and Policy Analysis Unit meeting material needs, and promoting durable solutions. undertook an assessment of the urban refugee policy framework and commissioned several case studies, When refugees take up residence in an , including an assessment of the situation in Cairo. The whether or not this is approved by the authorities, evaluation noted that the demographic assumptions of the UNHCR’s primary objective will be to preserve and policy—namely, that the majority of urban refugees were expand the amount of protection space available to young men—was not evidenced by data (Obi and Crisp them and to the humanitarian organizations that are 2001). The evaluation also found significant problems with providing such refugees with access to protection, the implementation of the policy’s focus on self-reliance. solutions, and assistance (UNHCR 2009b: 4) In Cairo, UNHCR-Egypt took steps in 1997 to explore the possibility of offering vocational training and providing Without preempting our conclusions, let us indicate at the microcredit opportunities to female refugees to start small outset that despite the improvements made by UNHCR- businesses, but the Egyptian government refused to permit Egypt in its revised 2009 policy, our findings indicate that the microcredit programs (Sperl 2001). Since this time, “protection space” for urban refugees in Egypt has shrunk UNHCR-Egypt has struggled to develop economic self- over the past 10 years due to the arrival of thousands of new sufficiency programs that the Government of Egypt will refugees in Cairo without a corresponding and proportional approve and which will ensure adequate livelihoods for increase in funding and durable solutions for most refugees. refugees residing in Egypt. From the time of these reports At the same time, chronic problems—Egypt’s restrictive

Legal and Policy Frameworks and Policy Legal legal framework and lack of widespread implementation of in 2001 until the present, it has been clear that integrating 4 refugees locally in Cairo would be difficult and unlikely, existing rights, UNHCR-Egypt’s budget and staff constraints, CH2: mainly due to restrictive host country labor laws. In this limited capacity and coordination among stakeholders, context, UNHCR policies designed to reduce refugees’ donor fatigue—continue to contribute to a low quality of dependence on aid actually led to destitution (Sperl 2001). life for many refugees in Cairo. In addition, the negative impact of the 1997 UNHCR-Egypt policy is still being felt In 2009, UNHCR changed its policy towards urban refugees, within refugee communities in Egypt, and it is perhaps too partly as a result of its experiences in helping some 400,000 soon to see the widespread impact from the revised 2009 of an estimated 2 million Iraqis who fled Iraq after 2003, policy. Lastly, the recent revolution in Egypt negatively most of whom went to big cities in Jordan, Syria and Egypt. affected refugees in Cairo in the short-term; it remains to be The new policy focused more specifically on protection. seen if in the long run the effects of the revolution will be In order to expand protection space in urban areas, the positive or negative for the local population and for refugees. 2009 policy calls for establishing reception centers in 2.2 Legal and Policy Frameworks for Refugees Refugee Livelihoods 4 The financial requirements for Egypt’s operation in 2012 are slightly higher than at the beginning of 2011 and amount to $19.7 million. CH3: During the course of 2011, Egypt’s budget increased significantly due to the supplementary needs for the situation in Libya. In 2012, the additional needs resulting from the Libya crisis have been included in the comprehensive budget. These budget increases will have minimal, if any, effects on Iraqi and African refugees in Cairo.

10 CH2: Legal and Policy Frameworks inter inter Labor Laws , to attend Egyptian public primary public Egyptian attend In, to 2000, schools. 81). In practice, these rules have not always been adhered been adhered not always these rules have 81). In practice, adopt to slow ministries were Egyptian either because to, easily circumvented. new rules or because the rules were further. be explored to Nevertheless, this loophole ought is often based on employment to access nationals’ Foreign of workers 10 per cent rule is that but the general reciprocity, Only civil service is can be foreign-born. company in any and Fakhoury (Di Bartolomeo, of Egypt nationals reserved to permits must obtain work nationals 2010). Foreign Perrin UNHCR- It for prudent be might employers. their through Reservation on Article prevents 24 (labor legislation) Iraqi, to applies and visas work acquiring from refugees by recognized refugees Somali, and Eritrean Ethiopian Sudanese—whetherUNHCR-Egypt. or migrants— refugees under the work the right to granted been technically have few (2004), but in actuality, Agreement Freedoms Four cumbersome, the complete successfully to able been have Palestinians one. obtain to required process lengthy since visas work obtaining restrictedfrom been have the labor market in them from excluded laws Egyptian for all visas is difficult obtaining work 1978. Additionally, to years the enactedhas over policies Egypt as foreigners, competition, foreign its domestic labor marketprotect from rates. high unemployment partdue in large the country’s to regulating be a loophole in the laws might there However, out, points Jureidini As in Egypt. employment refugee Articleis exploration Convention, 1951 the to of open 17 first The reservations. any did not enter which Egypt to “The shall States Contracting of Article paragraph 17 states: in their territory staying lawfully the refugees to accord of a foreign nationals to accorded treatment most favorable to the right as regards country in the same circumstances, (Jureidini 2009: engage in wage-earning employment” issued Decree No. 24 allowing Sudanese children, Sudanese children, allowing 24 No. issued Decree alia this right expand to agreed the Minister of Education hurdles bureaucratic However, children. refugee all to exercising from most refugees and prevent in place remain Inthis right. Ministry 2004, the Egyptian of Education students only those refugee instructed accept schools to government- and documentation with UNHCR-Egypt The documents. among other permits, issued residence certificate, requirements—birth documentation extensive passporta valid identity (such national document or valid the school certificate the original from card), as refugee UNHCR-Egypt—have country from a letter and origin of majority and the vast of practice, this right in limited fees the schooling, resortprivate to to instead have refugees considerable without cannot pay which most refugees for Al-Sharmani(Azzam2009, Hilal2006, assistance Samy and In2008). Relief fact, Services—theCatholic primary NGO our education—told refugee facilitating for responsible registered any of aware not were they that team research though some public schools, Egyptian attending refugees very in attend small may nationals Sudanese non- refugee regarding in Cairo situation The numbers. the where in Jordan, the situation contrasts education 2012). Iraqis (Davis to schools opened explicitly government so. Over the years, however, there have been ministerial ministerial been have there however, Over the years, so. for exceptions provided have that and decisions decrees In the Minister 1992, Education of certain groups. refugee 11 11 Education Laws Education

Convention and the 1967 Refugee Protocol, placing and the 1967 Refugee Protocol, Convention when it did education right to restrictions on refugees’ In 1981, the Government of Egypt signed the 1951 Refugee signed of Egypt In 1981, the Government The two reservations that have had the greatest impact on had the greatest reservations two have that The on Article those placed are living in Egypt populations refugee primary22 on free and Article education 24 on employment. that the Government of Egypt does not consider local does not consider of Egypt the Government that within its borders. refugees a viable solution for integration Government of Egypt expects that refugees recognized by by recognized expects of Egypt refugees that Government or countries third to will be resettled in Egypt UNHCR-Egypt country their to states explicitly the MOU return of origin: The determination of individual requests for refugee refugee for of individual requests determination The as has been the UNHCR-Egypt, is done by in Egypt status a signed of Egypt 1954, when the Government case since The Memorandum of Understanding (MOU) with UNHCR. Egypt has not adopted any domestic legislation to to domestic legislation any has not adopted Egypt is no national There the 1951 Convention. implement Egypt. in status refugee of determination the for procedure Egyptian children and lack of basic social services and lack of basic poor children Egyptian for Government Egyptian the that Officials felt strongly Egyptians. foreigners. towards to divertresources its cannot afford those guaranteed to citizens.” The reasons provided by the by provided reasons The citizens.” to those guaranteed high economy, officials included: struggling government opportunities lack of educational for rates, unemployment Manpower as well as the National Council of Childhood of Childhood Council as the National as well Manpower Grabska as interviewed by (2008: and Motherhood (NCCM), as same rights the to access have should not “refugees 77), relief and assistance) and 24 (labor legislation and social legislation (labor 24 and assistance) and relief from officials government Egyptian to security). According Health, Labor and (MOFA), Affairs the Ministries of Foreign Egypt ratified the 1951 Convention on May 22, 1981, with on May Convention the 1951 ratified Egypt Articlesreservations to (), 20 status), (personal 12(1) primary to public to 22(1) (access 23 (access education), a more robust and sustainable framework of legal rights and sustainable framework robust a more successful public services facilitate to to and access in order resettlement. for those ineligible for local integration limits the durable solutions available to a segment of urban a segment to solutions available limits the durable of this refugee likely permanence The in Egypt. refugees develop need to the urgent underscores in Cairo population refugee services in Cairo, but they are usually not eligible for for not eligible usually but they are servicesrefugee in Cairo, and North in Europe because most countries resettlement and do convention of the OAU not signatories America are thus convention OAU their criteria. Adopting not recognize UNHCR policies. After 2004, many Sudanese and Somalis Sudanese in 2004, many After UNHCR policies. Convention. under the OAU as refugees accepted were Egypt for eligible criteria are OAU under accepted refugees Those restrictions and limited effective protection (Olwan 2009). (Olwan It protection restrictions effective and limited which has Convention, is also a signatory 1969 OAU the to than status refugee for those eligible criteria for broader Status of Refugees and the 1969 Organization of African of African Refugees of and the 1969 Organization Status is a signatory Egypt of Refugee Convention. Unity (OAU) but with heavy and the 1967 Protocol, the 1951 Convention these rights for reasons that will be explored below. below. be explored will that reasons for these rights in Egypt refugees for protection pillars of international The the to Relating Protocol the 1967 the 1951 Convention, are law due to a number of prohibitions and restrictions and of prohibitions number a due to law rights do when Even government. the by put in place utilize often to unable are refugees on paper, exist Refugees in Egypt have only a few rights under Egyptian Egyptian under rights a few only have Refugees in Egypt

CH3: CH3: Refugee Livelihoods Refugee

CH3: Refugee Livelihoods Egypt and/or BPRM to assess the local labor market with a repatriation or cross-border livelihoods and identities (see: view towards which labor sectors or companies are looking Polzer 2008). Policy-makers often shy away from discussing

for workers but have not exhausted their 10 per cent of the local integration of refugees, worrying that it would CH3: foreign-born workers rule. In general, it could be beneficial to not be politically palatable to host governments. However,

open a dialogue with employers on their labor force needs. not discussing integration issues can be dangerous as well, Livelihoods Refugee Table 1: Rights According to Different Refugees Settled in Cairo “Refugees” East Africans: with Closed Sudanese Iraqis Recognized Files Palestinians Refugee Livelihoods Yes, on paper; in No No No No

Right to practice, no (GoE reservation (GoE reservation (lack legal resi- (Egyptian Law CH3: Work (Four Freedoms to refugee con- to refugee con- dency) 1978) Agreement 2004) vention) vention) Yes, on paper; in Yes, on paper; in Yes, on paper; in No No Right to practice, no practice, no practice, no (lack legal resi- (Egyptian Law Public (Four Freedoms (Decree 2000) (Decree 2000) dency) 1978) Education Agreement 2004)

Yes, public Yes, public Yes, public May use public Yes healthcare on healthcare on healthcare on health facilities (no restrictions) Right to the same basis the same basis the same basis but must pay Public as uninsured as uninsured as uninsured full fees because Egyptians Egyptians Egyptians they are not (Decree 2005) (Decree 2005) (Decree 2005) legal residents.

both for refugees and hosts. Lack of integration means a Without expanded rights, including the right to education lack of rights and for refugees, spells discrimination and an and the right to work, refugees in Egypt have no real inability to provide for their families. It also means a lack of chance for local “integration,” one of UNHCR-Egypt’s three understanding of local laws and can, inadvertently, lead to “durable solutions” (Crisp 2004). While local integration is undesirable behaviors. It also can result in hosts, particularly often conceptualized as a “durable solution” and meant to the poorer segments, perceiving refugees as “privileged” be a permanent solution to protracted refugee situation since refugees are provided assistance while not working. (see: Jacobsen 2001; Meyer, 2008), it can also be an Emphasis on local integration—whether permanent or “interim” solution. The social scientific conceptualization of interim—can lead to refugees being perceived by host integration considers it a process of interaction between governments as an opportunity rather than a burden. refugees and hosts and does not need to preclude eventual 2.3 Legal Frameworks for Human Rights Protection The Government of Egypt is signatory to a number of legal right to work in Egypt, this agreement would likely international conventions, some of which potentially constitute the framework by which future labor rights impact the rights and services afforded to refugees in Egypt. for refugees would be granted. This agreement provides

Legal and Policy Frameworks and Policy Legal limited rights and freedoms to migrant laborers. However, Egypt became a signatory to the United Nations’ Convention it explicitly states that domestic workers do not qualify as

CH2: on the Rights of the Child in 1990 and notably did not “laborers” under this agreement. Furthermore, human enter any reservations upon ratification. Article 22 of rights organizations have noted frequent violations of this Convention explicitly states that refugee children this agreement by the Government of Egypt, including are protected under the statutes of this agreement. One allegations of torture and the racist treatment of migrant key aspect of this Convention is that Article 28 stipulates workers by law enforcement in Egypt (EIPR and FIDH 2007). the rights of every child to free and compulsory primary education and that all children should be able to access The government also agreed to the United Nations’ vocational education if so desired. In practice, however, most Convention Against Torture and Other Cruel, Inhuman or refugee children are unable to attend public schools due to Degrading Treatment of Punishment in 1986. However, perceived legal barriers (whether real or misunderstood), there are widespread allegations that the police routinely cost, and cultural and linguistic barriers. All refugees are engaged in torture. Refugees reported their anxieties that prohibited from vocational training in Egypt. The protection they would suffer physical abuse from Egyptian police if of these rights on paper thus does not guarantee that refugee they were ever arrested. Despite Egypt’s ratification of this children receive their full rights in practice (OHCHR 1989). convention, there is no assurance that refugees in Egypt are

Refugee Livelihoods safe from abuse, wrongful detention or harsh treatment if Egypt is a signatory to the United Nations’ International taken into custody for any reason. These concerns have been CH3: Convention on the Protection of the Rights of All Migrant realized in recent years: UNHCR-Egypt and human rights Workers and Members of their Families, which went organizations have criticized the Government of Egypt for into effect in 2003. Though refugees do not have the detaining, mistreating and forcibly returning illegal migrants

12 and asylum-seekers attempting to cross through the Sinai Peninsula into Israel (UNHCR 2008; Human Rights Watch 2009).

CH3: 2.4 Trends in Durable Solutions

Refugee Livelihoods Refugee UNHCR-Egypt has responded in varying ways to the Beginning in 2007, Sudanese refugees led protests against legal constraints placed upon them by the Government UNHCR-Egypt, advocating for increased resettlement of Egypt when it comes to providing durable solutions opportunities. Though negotiations were sometimes often for refugee populations in Cairo. Both the Government tense, UNHCR-Egypt began to increase the numbers of of Egypt and UNHCR-Egypt have promoted voluntary cases recommended for resettlement in a third country. repatriation as the preferable durable solution for the Following the Egypt’s revolution and a new wave of protests, Refugee Livelihoods waves of Sudanese, East African and Iraqi refugees High Commissioner for Refugees Gutierrez announced who have arrived over the past few decades.5 a “new start” for refugee resettlement for UNHCR- CH3: Egypt, announcing a new annual resettlement target of Beginning with the waves of Sudanese refugees who fled 2,000 cases. This number was several times higher than to Egypt in the 1980s during the war in Southern Sudan, resettlement rates had been in the mid-2000s (Kagan 2011). UNHCR-Egypt performed RSD for each refugee applicant UNHCR-Egypt reported to our team that five additional staff in accordance with the MOU between the Government of members were assigned to review UNHCR-Egypt’s database Egypt and UNHCR-Egypt. From 1978-1995, the Sudanese of resettlement files to identify particularly vulnerable in Egypt additionally benefited from the terms of the Wadi cases that may be eligible for third country placement. El Nil agreement between the Governments of Egypt and Sudan. This agreement granted Sudanese in Egypt Other refugee populations in Egypt have had less volatile (refugees and ordinary migrants) rights of education, experiences in regards to durable solutions. Perhaps employment, health services and property ownership. learning from past mistakes with the Sudanese refugee This agreement ended in 1995 following an assassination population, UNHCR-Egypt granted all Iraqi asylum-seekers attempt on President Mubarak in Ethiopia, which the refugee status on a prima facie basis without undergoing Government of Egypt blamed on Sudanese Islamists. RSD.6 This qualifies Iraqis for international resettlement; thousands have been resettled since the first wave began Between 1995-2004, Sudanese refugees in Cairo were arriving in Egypt in 2003. Likewise, refugees from Somalia, afforded only the limited protections provided in Egypt Eritrea and Ethiopia were registered either on a prima facie under their MOU with UNHCR-Egypt. However, those basis or through individual RSD. Recognized refugees from recognized as refugees by UNHCR-Egypt were eligible these countries have been eligible for repatriation in third for repatriation in third countries during these years. Of countries, and many have been resettled over the years. the 20,700 Sudanese who were recognized by UNHCR- Palestinians, in contrast, are not registered as refugees by Egypt between 1997-2004, 14,300 were resettled in third UNHCR-Egypt, and they are not eligible for resettlement.

countries. Significant protection gaps remained however: CH2: the 20,700 recognized Sudanese refugees constituted Voluntary repatriation is an option to all refugees at all only a fraction of the total number of Sudanese who times. Since 2008, UNHCR-Egypt has actively involved Legal and Policy Frameworks approached UNHCR-Egypt for asylum. Upwards of 60 per itself in assisting Iraqis with voluntary repatriation. cent of Sudanese cases during these years were rejected According to statistics from UNHCR-Egypt, as many as because the Sudanese could not necessary prove that, as 1,439 Iraqis left Egypt, either with UNHCR-Egypt assistance individuals, they had a “well-founded fear of persecution”; or spontaneously. In 2010, that number dropped to 548. In they were simply fleeing thegeneral violence of the war. 2011, the year of the Egyptian Revolution, only 445 Iraqis left Egypt despite the increased instability and worsening To rectify this situation, in 2004 UNHCR-Egypt began to quality of life. (UNHCR 2011b, 2011c). The declining number recognize Sudanese refugees under the criteria of the of returns may indicate that, despite worsening conditions in Organization for African Unity (OAU), which recognizes Egypt, some Iraqis and other refugees may never voluntarily refugees fleeing the violence of war even if individuals return. Furthermore, UNHCR-Egypt officials indicated to our did not experience targeted persecution. Problematically, research team that these returns are not always sustainable: however, switching to the OAU criteria for RSD disqualified a number of “returnees” from Egypt to Iraq ended up many Sudanese refugees from international resettlement, leaving Iraq once again to seek asylum in Jordan or Syria. since most host countries in Europe and North America do not recognize the OAU’s criteria. Thus from 2004 onward, Likewise, only a small number of Sudanese have returned, Sudanese refugees had an extremely difficult time in trying and it is unlikely that many will return to South Sudan to get resettled internationally, despite the fact that this was until the relationship between the governments of the the preferred durable solution for most Sudanese refugees. North and South have stabilized. In 2011, 333 Sudanese and Southern Sudanese were assisted with returns by At the same time, prospects for locally integrating the UNHCR-Egypt, and similar numbers of Sudanese returned Sudanese improved somewhat in 2004. In this same year, the year prior (393 Sudanese). To give perspective, a total the governments of Egypt and Sudan entered into the “Four of nearly 25,000 Sudanese asylum-seekers still remain in Freedoms” agreement, which provided Sudanese in Egypt Egypt (UNHCR 2011c). Few Ethiopians or Eritreans have with the legal right of work, residency and other freedoms. returned. According to the research by Fabienne Le Houerou 5 The Government of Egypt’s response to Palestinian refugees followed a different trajectory, owing to Palestinians’ unique legal status and claims within the international refugee system. The Government of Egypt’s varying policies towards Palestinians will be discussed in greater detail below. 6 UNHCR-Egypt did occasionally perform RSD with a small number of Iraqi asylum-seekers in exceptional cases, such as when an Iraqi was suspected of being a former Ba’athist.

13 (2006), many Ethiopians living in Egypt fear reprisal or rights include the opening of primary health clinics and prison upon return due to their roles in Ethiopia’s civil war. primary schools to refugees. On the other hand, these rights

are insufficient even on paper: refugees require education CH3: Local integration is arguably the durable solution that beyond primary school and have health needs beyond requires the most attention currently from UNHCR-Egypt primary care. More problematically, these rights often exist Livelihoods Refugee and its partners. On the one hand, a few promising steps only in theory and are not realized in actuality. The result is have been taken by the Government of Egypt to extend that many refugees of all nationalities live precarious lives some rights to refugees who are unlikely to ever resettle to in Egypt, where they are unable to support themselves a third country or repatriate to their country of origin. These or become full-fledged members of their host society. 2.5 Protection Threats: Before the Revolution Refugee Livelihoods CH3: Iraqis: Live Largely Outside of Local Society widows or women separated from their husbands or other male relatives; Egyptian men often harass them. Iraqis reported to our research team that they live largely outside of local Egyptian society: they seek privacy from I feel insecure every time I leave the house because I their neighbors, they tend to live on the outskirts of am harassed and abused in the streets and in public the city, and they report perceptions that Egyptians are transport systems. I am also afraid of being stopped potentially untrustworthy. Few reported direct threats to by security officers and asked to show my ID. If I am their safety; only a few reported being victims of petty theft not recognized by the UNHCR-Egypt as a refugee or street crime. Most frequently, Iraqis complained of being I could be arrested and deported back home. And defrauded by Egyptian “business partners” who pledged to now that the political situation in Egypt is not stable, open small businesses with Iraqis, only to disappear with there is uncertainty as to what is going to happen the Iraqis’ investment funds. On the part of the Egyptians, to me next or any other refugee for that matter. our team noted that Iraqis were blamed for affecting rent A Somaili Woman increases and the cost of food. Iraqis also face a certain level of discrimination due to Egyptians’ assumptions that all Iraqis are Shi’i.7 In at least one instance reported to our team, a Shi’ Even though I have a blue card [a UNHCR issued Iraqi boy was harassed in his primary school on account of his identification card] and can live legally here in religious affiliation. Iraqis are distinctive from the Egyptian Egypt, I experience a lot of harassment from the population on account of their dialect and thus can be “singled local men everywhere I go and the only time I feel out” in conversations. Iraqis are not racially distinct from safe and comfortable is when I am in the house. most Egyptians and thus do not experience racial prejudice. A Sudanese Woman Sudanese and East Africans: High Levels of Discrimination Egyptians: Also Feel Insecure In contrast, Sudanese and East African refugees report However, lack of security does not affect solely refugees. high levels of racial discrimination from the Egyptian Prior to the revolution, we heard many stories about population. Many authors have documented the frequent Egyptians fearing arrests, beatings by the police and, verbal abuse that Sudanese, East Africans and even in some circumstances, torture. The Nadim Center, for Egyptian Nubians experience in Egyptian society. Certain example, was established in 1993 to provide services to professions in which Sudanese and East African refugees Egyptian survivors of torture and victims of state violence work also expose them to a greater risk of physical, and police brutality. Reportedly, police used torture in verbal, sexual, and emotional abuse. Their employers, for Egypt quite frequently to obtain information from people Legal and Policy Frameworks and Policy Legal example, often abuse domestic workers, and they have or recruit them to be informants. They often resorted to

CH2: little recourse in Egyptian law and society (Jureidini 2006). torture to force people to provide witness testimony in criminal cases. A psychiatrist we interviewed told us a story In Arab and African societies, kinship and social linkages about a young boy who had been tortured because he was are quite important and serve as informal protection either implicated or had witnessed a murder in his village. mechanisms. Some refugees, Iraqis and others, are fortunate He was rounded up and severely beaten to “confess” that enough to have their families with them, providing some he had seen the murderer the police was investigating. comfort and security. Most vulnerable are single women, 2.5 Protection Threats: After the Revolution The revolution created significant vulnerabilities and for weeks to have their appointments rescheduled. Monthly protection threats for all refugee populations in Egypt. cash stipends from Caritas to refugees were interrupted UNHCR closed its offices for several days and evacuated during the protests, leaving a number of refugee families in international staff during a portion of the uprisings in critical financial situations. There was a rise in both protest- January 2011. With the offices were closed, refugees were related violence and criminal violence during the revolution, not able to receive services they required, and those with creating palpable fear among refugee populations and appointments scheduled during the revolution had to wait the local Egyptian population alike. UNHCR reported to us 7 The Egyptian Muslim population is overwhelmingly Sunni. In contrast, only approximately 20 per cent of Iraqis are Sunni, creating a perception among Egyptians that most Iraqis come from a different sectarian background.

14 CH2: Legal and Policy Frameworks A young Egyptian man Egyptian A young A young Christian Egyptian man Egyptian Christian A young Egyptians: Experiencing Increased InsecurityExperiencing Increased Egyptians: very frustrating. We don’t have any rights here and here rights any have don’t We veryfrustrating. skin because of our discriminated are color. we before safe feel I used to is safe. think Cairo I don’t go to wouldn’t I I don’t. but now the revolution, badly people treated always have They the police. tell to it is difficult so much is changing, and now unpredictable will react; they are police the how a policeman. approach to which makes me afraid I am a Christian and I am vacuum.” “security a It’s On all sides. from subjected violations to constantly Christians 5, 2011 in Giza Muslims attacked March set and the church, desecrated in a church, gathered nothing. did and on looked army the while fire on it have been robbed and attacked by the locals. locals. the by attacked and been robbed have and subjected more to are women our Especially is and that the locals and abuse by attacks more Parents, both Egyptians and refugees, expressed increased increased expressed refugees, and both Egyptians Parents, after the of their children the safety about concerns we woman an Egyptian revolution, the Before revolution. 6th of October with her family to interviewed had moved the since However, neighborhood. a safe because it was “There are there. secure less and less feeling is she revolution they have “and said, she some bad people in 6th of October,” religion or ethics no have They revolution. the since spread can so anyone the revolution since is no police and there go outside alone.” children I do not let my purse. take your reported who individual refugees were there the same time, At positive some in lives their affected revolution the that Iraqis participated many in the example, For as well. ways, during the 18 days formed that groups neighborhood watch Iraqis reportedThese that in Januaryof the revolution 2011. an important knowthis was get to to in helping them step like part and feel neighbors their community. their local of Refugeereportedalso stakeholders Eritrean, their that Somali reportedEthiopian, and Sudanese clients similar Since protests. of the during the initial days experiences that of community cohesion feelings January 2011, however, of the revolution “emergency” during the initial place took furtherand necessary that are ensure abated, steps to have local communities. their into integrated better are refugees Although many Egyptians did not trust and feared the policythe feared and trust not did Egyptians many Although particularly safe, in they did feel the revolution, long before Egyptians the revolution, neighborhoods After they knew well. the same fear of this study shared interviewed in the course refugees. and anxiety by and security safety about expressed 15 Iraqis: Fearful Iraqis: African Refugees: Don’t Feel Safe Feel Don’t Refugees: African I am afraid of the way the locals look at us. I don’t I don’t us. the locals look at way of the I am afraid who refugees of heard have I anymore. safe feel the UNHCR-Egypt closed its office and left closed its office and the UNHCR-Egypt protect to without anyone stranded were refugees shops because go the coffee to afraid I am even us. as to what may happen next. What if the people do What happen next. may what as to will happen What anymore? us in Egypt not want started the demonstrations When in Cairo, us? to I don’t feel safe here in Egypt now more than ever than ever more now in Egypt here safe feel I don’t It situation. because of the current is unpredictable

Other refugees were also fearful. A male Ethiopian refugee said: also fearful. refugee A male Ethiopian Other were refugees them there, while at the same time fearing to remain in Egypt. in Egypt. remain to the same time fearing while at them there, offered to return any Iraqi citizens to should they citizens returnIraqi any to offered spoke with of the Iraqis some we However, return. wish to happen to could of what fear Iraq for to return to afraid were not aware of any specific violent threats against Iraqis, given given against Iraqis, threats specific violent of any not aware the perception during the revolution, the number of deaths the Iraqi in Cairo embassy Reportedly, very was real. of fear in the aftermath of the revolution, fearing to venture too too venture to fearing in the aftermath of the revolution, servicesand NGOs from resources access to home from far was team the research Though of Cairo. in the center located St. Andrews and other organizations held psychosocial psychosocial held organizations other and Andrews St. anxiety. support the Iraqis’ to help respond sessions to and security about safety fears it appears that However, further to Iraqi themselves refugees isolate caused many fear during and after the revolution was significantly higher significantly was during and after the revolution fear trauma to perhapsrelated populations, than other refugee wartime the veryexperienced. from they had fighting recent in Egypt for a long time. These applications represented represented applications These a long time. for in Egypt in Egypt. futures and safety their about fears growing Iraqis’ anxiety and also reportedStakeholders Iraqi that refugees’ during the revolution. UNHCR also reported to our team that that UNHCR also reported our team to during the revolution. for refugee status for numbers of applied significant Iraqis the first time after January though they had been 2011, even InUNHCR- Iraqis of number a to interviews, applied our who in light lives their for fears expressed status refugee for Egypt particularly security in the Egypt, of the deteriorating situation by the entire Egyptian population after the revolution. after population the revolution. Egyptian the entire by more than usual were being evicted or reported that than usual were more on their apartment. the rent raising were their landlords xenophobic increasing both to attributable was This experienced hardship economic and the real attitudes African refugees in Cairo even prior to the revolution. the revolution. prior to even in Cairo refugees African complaints also reported Refugees of all nationalities more many landlords: their with problems about UNHCR to revolution; African refugees were particularlywere vulnerable refugees African revolution; historylong the to due harassment of xenophobic to against and harassment discrimination racially-based that xenophobic attitudes increased during after and the increased attitudes xenophobic that

CH3: CH3: Refugee Livelihoods Refugee

CH3: Refugee Livelihoods 2.6 Recommendations CH3:

All refugees residing in Cairo are in need of expanded rights link quota numbers for local integration to the Livelihoods Refugee and protection. However, black Africans are particularly numbers of those resettled in order to maintain vulnerable because of widespread racial discrimination. pressure on UNHCR-Egypt and resettlement Indeed, we have observed much prejudice against the countries to admit significant number of refugees Other—refugees of color and refugees of different social who had lingered in Egypt for five plus years. class—by Egyptians and Iraqis alike. Iraqi refugees petitioned an international health NGO to designate particular days of • Train Law Enforcement about Refugee Rights. Police the week for services to the Iraqi community to avoid sitting officers are not well versed in refugee laws and often in the same waiting room with African refugees. The service times question the validity of UNHCR-issued refugee provider in question was very disappointed that UNHCR- documentation and resulting refugee rights. There is a Egypt would not allow them to institute this practice and need to work with the Government of Egypt to implement appealed to the research team to make a recommendation mandatory training for police officers—particularly that would override UNHCR-Egypt’s decision. Middle-class, those officers working in refugee neighborhoods— educated Egyptian service providers saw Iraqis as peers and to better understand refugees’ statuses and rights. treated them accordingly. They had much less appreciation • Re-interview Sudanese Refugees with Closed for the challenges African refugees faced and often dismissed Cases. We recommend that UNHCR-Egypt re- their plight saying: “They [African refugees] did not lose interview Sudanese refugees to find those eligible for nearly as much as Iraqis. They didn’t have much to begin resettlement. UNHCR-Egypt pledged to dedicate five with.” Sudanese, Somali and Ethiopian refugees reported staff members to review closed cases following the 2011 many incidents of racism in the form of verbal abuse and revolution and the subsequent protests at UNHCR. We physical assaults. They reported that racial discrimination recognize that this recommendation poses some risks; was often the root cause of unfair rent practices, limited UNHCR could decide that the Sudanese are not eligible access to health care and harassment by law enforcement for refugee status, and the refugees could lose all the (see also: FMRS 2006). Sperl (2001) speculates that the rights and services that they currently have as Persons local community treats Muslim refugees better than non- of Concern to UNHCR under the under the Organization Muslims. Grabska (2006), however, posits that racial/ethnic of African Unity (OAU) convention. Nevertheless, discrimination and hostility override shared religion. the alternative is a prolonged, protracted situation • Re-negotiate the 1954 MOU between UNHCR-Egypt without any prospects for any viable durable solution. and the Government of Egypt. This recommendation • Anti-Discrimination Training for Implementing comes from an analysis conducted by Michael Kagan Partners. There is a lot of scope for UNHCR-Egypt (2011); the research team concurs with his findings. In and BPRM to train their implementing partners to this new agreement, the Government of Egypt would understand race and class differences among refugee pledge refugee non-refoulement and would grant populations in Cairo as well as to institute and/ rights to refugees, including the right to work, but or monitor implementation of anti-discriminatory would n=ot be asked to permanently settle refugees. practices and behaviors while working with the UNHCR-Egypt would continue to do RSD, and the Egyptian government on extending a broader set Government of Egypt would respect their decisions. of rights and protections to all refugees. Training of UNHCR-Egypt would continue to provide support, current and future implementing partners is particularly which would considerably diminish the drain on important if UNHCR-Egypt will indeed increase funding

Legal and Policy Frameworks and Policy Legal Egyptian resources, but would need to provide much for refugee and local civil society organizations. less support if refugees were allowed to work. The

CH2: priority of durable solutions would be as follows: first, • Training for Refugee and Local Community Networks voluntary repatriation, second, resettlement and last, and Organizations. Refugee communities in Cairo local integration. UNHCR-Egypt would encourage live in isolation from each other and from the local repatriation with as much transparency as possible. Egyptian community. They often make assumptions After this, UNHCR-Egypt would prioritize international about each other that can lead to misunderstandings resettlement for those who have lived in Egypt for or prejudice. UNHCR-Egypt should organize training five years or longer and who have no prospects for programs, information exchange sessions and informal repatriation or local integration. Kagan’s arguments are gatherings of refugee community leaders and members commensurate with the notion that local integration to facilitate better cross-cultural, cross-religious and does not necessarily indicate permanent settlement. cross-sectarian understanding and communication. BPRM should fund an effort to identify or adopt existing • Egypt would grant permanent residency to those training materials and curricula to the local context. who truly cannot return or resettle, but could Refugee Livelihoods Refugee Livelihoods CH3: CH3:

16 CH3: Refugee Livelihoods CH3: Refugee Livelihoods Menial Jobs Iraqis: Unable to Work Legally, Reluctant to Take Reluctant Take to Legally, Work to Unable Iraqis: a different job that they were trained for as long as it was for as long as it trained were they job that a different interviewed all Iraqis we exception, Without desk job.” “a manual labor and jobs disdain for a profound expressed noting our data, confirmed Stakeholders [their] level.” “below in entrepreneurial only be interested to Iraqisthat tended the same At opportunities labor. and shunned manual reported our team to professionals health care mental time, below jobs menial up taken have who Iraqi refugees that of symptoms often qualifications display their professional counseling health mental and should receive depression In the remainder of this chapter we will discuss refugees’ refugees’ discuss will we chapter of this In the remainder particulara with employment informal and formal to access and opportunitiesemphasis on: the vulnerabilities by faced remittances) and (savings assets financial workers, domestic and living and housing costs as cash assistance, as well including will discuss other expenses, We conditions. chapters. in subsequent costs, and healthcare education as waged employment find able to are refugees many under protections but without any domestic workers, cooks, baby-sitters, Housekeepers, labor laws. Egyptian contracts— private servantsother and into enter gardeners, who citizens private agreements—with often times verbal put arrangements informal These need their assistance. exploitation. risk at for domestic workers refugee many adamant Iraqis of this project interviewed were in the course of education. their level not take jobs below they would that with their education jobs commensurate wanted All take willing to Some in Iraq. were experience and work other hand, sometimes turns a blind eye to refugees refugees to turns sometimes a blind eye other hand, labor restrictive These working economy. the informal in the international enormous pose for challenges laws but the inconsistent in Cairo, operating regime refugee some, working provide refugees towards attitude strategies opportunitiesalbeit very creative limited, for working and protecting refugees. livelihoods facilitating in the recommendations. discuss these strategies We has emerged, of livelihoods concept of the No clear definition the phenomenon. Chambers of the complexity illustrating the to refers “livelihood” that (1991) indicate and Conway a make people to used by assets and strategies capabilities, individuals and families allows A sustainable livelihood living. maintain to shocks, and stress from recover and with cope to provide to order its capabilities and assets in or enhance opportunitiessustainable livelihood the next generation. for at to other livelihoods It net benefits contributes also livelihoods In other words, the local and global levels. and sustain life. maintain the means used to to refer often are refugees Cairo’s urban other Similarly refugees, to cultural, financial, of legal, range with a wide confronted barriers speakers—linguistic in their non-Arabic and—for cases many In efforts sustainable livelihoods. to establish economy. informal the join to but alternative little have they 17 Refugee Livelihoods Refugee Access to Employment Employment to Access 3.1 Promoting Livelihoods and Livelihoods Promoting (UNHCR 2011). In these publications, UNHCR (UNHCR 2011). In these publications, Chapter 3: Chapter

domestic service does not constitute labor. As a result, a result, As domestic service labor. does not constitute able to find work, albeit illegally in the informal economy in work, economy find able to albeit illegally in the informal protections. with few sectors and occupations unregulated law under Egyptian all foreigners: for One loophole exists sponsorship and no competition from a similarly qualified from sponsorship and no competition (see also Buscher and Heller 2010). Despite citizen Egyptian Africans—are refugees—mainly some these restrictions, right to work. In practice, however, it is almost impossible for it is almost impossible for work.right to In however, practice, obtain the necessarythe Sudanese to permit required work Securing permit is an expensive, a work legal employment. for employer requires which process, complicated and lengthy barred from working in Egypt since 1978 (El-Abed 2005). The The 2005). 1978 (El-Abed working since from in Egypt barred Freedoms the Four situation: in an exceptional Sudanese are the Sudanese with the provides technically (2004) Agreement are registered with UNHCR-Egypt. Refugees closed with UNHCR-Egypt. with registered are workingresidency they lack legal from since barred files are been have permit.Palestinians work a for apply to required reservations to the 1951 Convention on article 24 (labor reservations the 1951 Convention to legally in Egypt. cannot work refugees mean that legislation) refugees who restrictionAfrican affects This and East Iraqi livelihood initiatives, in Cairo most refugees continue to face face to continue most refugees in Cairo initiatives, livelihood and economic self-reliance immense challenges in attaining Egypt’s previous chapter, in the indicated As self-sufficiency. Despite the pronouncements about the importance of the pronouncements Despite UNHCR-Egypt and its implementing partners implementing its and UNHCR-Egypt Cairo in hand, one the on that, framework legal a within operate on the legally and, work to refugees does not allow includes a more somber assessment of the obstacles many of the obstacles many somber assessment includes a more in seeking face its earlier than urban iteration. refugees work livelihoods, refugee on emphasis increased the Despite issues of protection and durable solutions (UNHCR 2011). and durable issues of protection of both 1997 and 2009 also emphasized Urban Policies The though the 2009 policythe importance of livelihoods, 23.1, Universal Declaration of Human Rights Declaration and Articles23.1, Universal for and all people, for 17-19 of 1951 Geneva Conventions) with it is closely associated in particular, urban refugees, Self-Reliance: Operational Guide on Refugee Protection in Protection Guide on Refugee Self-Reliance: Operational Urban Areas is a human right (Article work to the right that emphasized in the Agenda for Protection (UNHCR 2006; UNHCR 2003). (UNHCR 2006; UNHCR Protection for in the Agenda further in were highlighted livelihoods Issues of refugee publication recent UNHCR’s globally to frame livelihood as an essential protection issue issue protection essential an as livelihood frame to globally especially in situations, refugee of protracted in the context a acquired have livelihoods Consequently, urbansettings. and initiative Plus Convention in UNHCR’s place prominent there were few policies and programs to address refugees’ refugees’ address to programs policies and few were there However, solutions in Cairo. livelihoods long-term needs for began years of the new millennium, UNHCR in the first primarily on assisting and preparing refugees for eventual eventual for refugees primarilypreparing and assisting on was of Egypt the Government since or resettlement, return a result, As of refugees. permanent integration to averse most important step towards increasing refugees’ protection, protection, refugees’ increasing most important towards step their to and contributing solutions, durable promoting In focused UNHCR-Egypt the past, well-being. long-term Improving the livelihoods of Cairo’s refugees is the single is the single refugees of Cairo’s the livelihoods Improving

CH3: Refugee Livelihoods Refugee

CH3: Refugee Livelihoods to mitigate this situation. This stands in sharp contrast to Some Iraqis with resources at their disposal attempted to many mental health approaches that suggest that keeping start small entrepreneurial ventures: open a bakery or a refugees busy decreases social isolation and serves as barbershop, serve as middlemen on commission in real a protective factor minimizing the risk for depression. estate sales, or operate a small grocery store. However, many were told that in order to start a business in Cairo they needed Iraqis with relatives or friends in the United States were an Egyptian partner. Several Iraqis we spoke with have either appalled that many were not able to re-establish their been deceived by Egyptian partners or heard of others who professional careers and some had to take up menial jobs. In were swindled out of their money. One Iraqi man told us that some interviews with stakeholders, we observed that service when he and his parents first came to Egypt in 2007 they providers have supported Iraqi refugees rather classist opened a small market in the neighborhood. However, an Refugee Livelihoods attitudes towards menial labor and jobs not commensurate Egyptian neighbor, who seemed to be a good man, told them with their education. Refugee service providers, particularly that they had to share the profits because they were illegal. CH3: middle-class Egyptians, bemoaned the fact that refugees At first they did not believe him, but after several weeks of resettled in the United States were encouraged to enter the nagging they gave in. Reportedly, he stole 10,000EP from labor force as quickly as possible regardless of the type of them. In 2009 they took him to court, but at the time of our employment that was available to them. They were very interview in December 2011 the case had not been settled yet. supportive of Iraqi refugees’ decisions to look for opportunities in Europe rather than in the United States or Canada. 3.2 Vulnerability of Domestic Workers Domestic work—including house cleaning, cooking, and me money and helps me with many things” (Jureidini childcare—is often one of the few fields in which refugees are 2009: 87). Based on his research, Jureidini found that able to find work. In our analysis of refugees’ participation in male employers were often the perpetrators of sexual domestic labor, we partnered with Dr. Ray Jureidini (formerly harassment. However, because of the shame associated of the American University in Cairo, now with the American with the abuse and the lack of legal protections in place University of ), who has published extensively on issues for domestic workers generally, abuse is rarely reported. of domestic labor in Egypt and throughout the Arab world. We have also analyzed other publications on this topic and Abused refugees have little recourse in terms of getting interviewed many domestic workers, particularly women. protection from the Egyptian legal system. While Service providers and refugee advocates we spoke with have interviewing a female family physician working with also indicated that this group requires particular attention. African refugee women we heard a story about a Sudanese domestic worker who was raped by her employer in a dark African Refugees: Eager to Work, At Risk for courtyard. Distressed by the situation she ran into the street Exploitation and a passer-by, a male doctor, summoned the police to help the victimized woman. When the police arrived they Many African refugees—Sudanese, Somalis, Ethiopians and said that in order to make a credible claim the victim would Eritreans—work in the informal economy. Women typically have to have an affidavit signed by a medical doctor. The work as domestic servants, providing household cleaning passer-by offered to attest to what he saw—after all he was and childcare. Men who are able to find work often find a doctor—but the police told him that the affidavit had to be employment in the service sector as chauffeurs, deliverymen issued by a doctor who works for the police to be credible. or gardeners. Somali and Sudanese women, in particular, Obviously, there was no such doctor in the street. The police have had consistent success in finding employment as told the woman to go home. In her case, “home” was the domestic workers in private homes. Accurate statistics house of the rapist since she was a live-in housekeeper. do not exist regarding the number of domestic workers in Cairo. But it is believed that for thousands of refugees In addition to sexual harassment and sexual exploitation, domestic workers faced other forms of abuse. When she in Cairo, domestic work is the only type of employment 8 available, and it has proven to be a crucial source of income first arrived in Cairo, Salima, a young Sudanese woman, for their survival. Virtually every African refugee woman worked as a housekeeper for an Egyptian family. The lady we spoke with worked as a domestic worker or baby- of the house took her passport and would not return it sitter in an Egyptian household, as there is high demand when Salima needed the passport to register with UNHCR- among middle- and upper-middle class Egyptian women Egypt. Only after Salima waived her salary, the Egyptian employer returned the passport. Salima eventually quit,

for domestic workers. However, pay is typically inadequate CH3: and insecure. Domestic workers are not legally considered having become ill from working long hours with only

“workers” and thus are not protected by Egyptian labor one meal a day. Our research assistants told us other Livelihoods Refugee laws, nor are their contracts valid legal documents. accounts of employers strip-searching their domestic employees whenever they were suspected of theft. In a survey of 633 foreign-born domestic workers in Cairo conducted by Jureidini (2009), 10 per cent of interviewees Refugee men also work in the informal economy, though complained of sexual harassment, including rape, there is less demand for their labor and subsequently many find it difficult to get hired. Based on group interviews

Refugee Livelihoods inappropriate touching and demand for sexual favors. Refugee Livelihoods Those who tried to refuse were fired or threatened with conducted by our research assistants at Refuge Egypt, many Sudanese men reported working as chauffeurs, CH3: firing. One interviewee said: “The husband comes to my CH3: room every night for sex. I can’t say no because he gives running small errands for employers or working as deliverymen. Though some of these men reported good 8 Pseudonyms have been used to protect the anonymity of interviewees.

18 working relations with their employers, other complained Egypt, African refugees explained the reasons given by of racism, unpaid wages and unjustified dismissals. employers for stopping employment: “It was Mubarak who allowed you in here and now he is gone, so it’s time For obvious reasons, employment in the informal economy for you to go too”; “We don’t need you here now”; “We is not very secure. This insecurity has been exacerbated have our own issues to deal with.” As the economy is not after the revolution. African refugees reported being likely to recover soon, refugees are likely to continue facing “laid off” from their domestic work, gardening and other increased economic vulnerability in the months to come. unskilled positions. In community meetings with UNHCR- 3.3 Financial Assets: Savings and Remittances Iraqis: Running Out of Savings, Relying on to collect rent money from tenants living in the house 9 Remittances her late husband built. We also heard of a case of an Iraqi man who was arrested because he received a large Iraqis and refugee service providers interviewed in the course money transfer from Iraq of $7,000 and the police claimed of this project indicated that many Iraqi refugees continue to he was using the money to aid terrorists. The police live on their savings. There is a general perception that Iraqi confiscated the funds and detained the man. UNHCR- refugees are fairly well off. However, the Iraqi refugees we Egypt got involved and presented him with the option of spoke with worried that these resources were diminishing deportation to Iraq or going to another country. He chose quickly, and we heard reports that some Iraqi families to go to Syria because he had business connections there. had reached such a precarious position that they had to choose between educating their children and paying for A survey of Iraqi households conducted by the World Health medication. While it is probably true that savings or funds Organization (WHO) and the Ministry of Health (MOH) from property sales are drying up, visits to Iraqi households indicated that an estimated 60 per cent of Iraqi households suggest that they are trying to hold onto urban, middle- do not have sufficient financial support because of lack of class standards of living and are better off than African resources to meet their basic or other special needs (WHO and refugees living in Cairo. Even though most Iraqi apartments MOH 2009). However, that means that 40 per cent are doing we visited were sparsely furnished, many were located in relatively well. If they could work legally in Cairo, the majority nice residential neighborhoods, primarily in 6th of October. of Iraqi households would most likely be self-sufficient. Furthermore, each household we visited had a television, Other Refugees most interviewed Iraqi refugees had Internet and cell phones as well as basic but sufficient furniture for household Some Sudanese, Somali and Ethiopian refugees we members. In contrast, most Sudanese and Somali refugees interviewed also received money from friends and lived in overcrowded dwellings in poor neighborhoods in relatives. The Somalis who received remittances from central Cairo with insufficient furniture and few amenities. their families did not work, and some were able to Many lived with roommates—extended family members or pay for their education with this money. However, the non-relatives—whereas Iraqis did not. Some African refugee sums were small and rarely exceeded a couple hundred women opted to work as live-in domestics simply because dollars every few months. No African refugees reported they could not afford to rent a room, much less an apartment. having any savings. As one Ethiopian woman told us: To supplement their dwindling savings, a considerable I work six days a week and more than 16 hours a day and number of Iraqi households continue to receive remittances, the pay is very little. I don’t have any savings and my life either from properties in Iraq or relatives living in Iraq is from hand to mouth and I am worried about my future. or elsewhere in the world. In one of the first Iraqi families Every African refugee interviewed expressed similar we interviewed, the mother—a middle-age widow with concerns about their vulnerabilities from living “hand to an engineering degree from an American university— mouth.” Those refugees with closed files are even more told us that she would not register with UNHCR-Egypt vulnerable since they lack the ability to receive services because then she would not be able to travel to Baghdad and cash assistance from Caritas and similar organizations. 3.4 Cash Assistance Discussing the situation of Iraqi refugees, UNHCR-Egypt well as support the local infrastructures in coping with CH3: pledged assistance, but not direct cash assistance: the impact of the presence of large Iraqi populations in CH3: their territories. Significantly, UNHCR’s support…to this Refugee Livelihoods Refugee Refugee Livelihoods Refugee The challenge of assisting vulnerable refugees in the region social network will also have a positive spillover effect should not be resolved through direct cash assistance. upon host communities and the most vulnerable within.” Assistance to Iraqis in the region should be delivered to (UNHCR Strategy for the Iraq Situation, Revised 2007: 4). host community networks, such as national social agencies and civil society. This methodology will allow UNHCR Despite this initial policy position, UNHCR has provided cash to simultaneously reach more beneficiaries, provide assistance to Iraqi refugees in Jordan and Syria (Davis and

Refugee Livelihoods UNHCR more leverage with host country authorities to Taylor 2012: 41). In Egypt, cash assistance is distributed by advocate for more effective protection standards, as Caritas; it is distributed to families on the basis of need and CH3: 9 UNHCR-Egypt and the Government of Egypt require refugees returning to their country of origin to close their cases with UN- HCR-Egypt. Refugees may re-open their case once they return. However, refugees hoping to travel frequently between Egypt and Iraq— as in the case of this woman—have preferred not to register with UNHCR-Egypt in order to maintain their mobility.

18 19 family size, and refugees of all nationalities expressed the Most interviews included narratives about interruptions importance of this cash assistance in meeting their basic in cash assistance, the need to re-apply and long waits needs. However, because cash assistance is only distributed for a decision regarding reinstatement of cash assistance. to refugees with open files, cash assistance is not available for The research team interviewing refugees in Amman the most needy population—those with closed files. Somalis, reported similar stories of interrupted cash assistance Sudanese, Ethiopians and Eritreans are more likely to receive payments (Davis and Taylor 2012). The steady decrease of cash assistance than Iraqis, due to the lower average wealth of subsistence allowances, combined with the progressive African refugee families as compared to Iraqi refugee families. reduction of UNHCR-Egypt support for health and education, has put many refugee families in a crisis situation. Given the Egyptian government’s restrictions on refugees’

Refugee Livelihoods right to work and on vocational programs (the government Sadly, the situation has not improved much in the 10 years prefers to reserve vocational training to only those refugees since Sperl’s study of the Iraqis (Sperl 2001) and Grabska’s

CH3: who signed up for voluntary repatriation programs), research on Sudanese refugees in Cairo (Grabska 2008). NGOs have had limited impact on refugees’ labor force The majority of NGO-operated programs do not focus on participation and livelihoods, apart from providing limited helping refugees improve their livelihoods while in Egypt, cash and in-kind assistance. Our interviews indicate that but rather aim at meeting people’s immediate needs existing cash support is insufficient and unreliable. Virtually or helping them prepare for resettlement or eventual every refugee who has been receiving cash assistance repatriation. As our colleagues found in Amman, Jordan: mentioned being strapped for cash at some point, having the cash assistance interrupted for no apparent reason The situations of Iraqis in Jordan are no and/or needing to re-apply, and, as a result, having longer as “emergency” warranting relief. Thus, difficulties making ends meet and planning their expenses. some funding targeting Iraqis may be better directed towards development that will benefit the refugees, the local communities, and other migrant communities. (Davis 2012: 74) A Sudanese woman reported receiving 380EP every two months from Caritas in the fall of 2010, after Those who have had refugee status applications rejected a couple of months the amount was increased to and are residing in Egypt illegally are excluded from any 960EP, but then the cash assistance stopped. She form of formal assistance. The Egyptian government does was supposed to apply again in January 2011 but not support any irregular migrants or refugees whose because of the revolution her appointment was claims have been rejected. We visited two different social cancelled. Her rent—about 400EP/month—was service agencies working with poor Egyptian families— two months overdue at the time of our interview. one affiliated with the Ministry of Social Welfare and one affiliated with the Coptic Church—and both reported A Sudanese family of nine was receiving 1800EP that they could not provide much assistance for refugee every two months. The father reported that it was families, especially in the form of cash assistance. One of the not enough to cover the family’s expenses. His agencies provided skills training (at the time of our site visit children are often unable to go to school because the training focused on first aid) to a mixed group of Iraqi, they do not have the money for transportation. Kurdish, Sudanese and Ethiopian refugees—approximately It costs him 10EP every day for breakfast and 20-25 people—and the other used to provide vocational transportation for each child or 50EP for five of training with UNHCR support, but the funding ended and the school age children in the family. When the at the time of our research they mainly provided social electricity bill—about 40EP per month—arrives support or distributed donated clothing or furniture. he does not send the children to school for a couple of days to save money to pay the bill. 3.5 Housing Costs and Living Conditions Housing and living conditions varied widely between They were very dissatisfied with living conditions in Cairo. refugee communities as well as within each national group. Most refugee interviews for this study were Iraqis were often quite particular about their neighbors. conducted in homes, and detailed observations were Iraqis indicated that they prioritized neighborhoods that recorded about the dwellings and furnishings. Refugees were quiet, had few foreigners and were populated primarily by “respectable” residents. One Iraqi man said the following

were also queried about the cost of rent and asked CH3: to describe their living situations in their countries of about the need to move to another apartment: “We first lived origin and compare them with the situation in Cairo. in an apartment in Nasr City but had to move to another Livelihoods Refugee apartment, because we do not want any foreigners in the Iraqis area.” Another woman specifically noted that she did not want to live near students, Palestinians or others whom she Egypt’s rent-protection laws ensure that Egyptian citizens do viewed as potential “trouble makers.” Some Iraqi households not have to pay exorbitant rent. However, these protections indicated that proximity to their children’s school was do not apply to foreigners, including refugees, who often Refugee Livelihoods

important, both to reduce the cost of daily transportation to Refugee Livelihoods pay up to 10 to 15 times more than Egyptian nationals (Briant school and to protect the safety of their children by reducing CH3: and Kennedy 2004). Most Iraqis we spoke with were used to the distance they traveled to go to class. For the Iraqis that CH3: living in spacious houses with gardens or large apartments in could afford the higher rents of Cairo’s satellite communities, quiet residential areas in Baghdad or other large cities in Iraq. such as 6th of October, many preferred to move there for

20 CH3: Refugee Livelihoods CH3: Refugee Livelihoods Egyptians rents” can amount to as little as 7EP (approximately $1) per as little as 7EP (approximately to can amount rents” system. rent the old cannot benefit from Newcomers month. to legally entitled are landlords system, rent” “new In the of each calendar the beginning at 10 per cent by rent raise increased reported their landlords that refugees Many year. in resulted which on their apartmentsrent the every year, find cheaper housing. to every years families moving few many share generally and poor Egyptians refugees While in the area in daily life, and burdens of the same concerns advantages. significant have Egyptians and housing, of rent Similarly to refugees, poor and working class Egyptians refugees, Similarly to of this projectinterviewed also struggled with in the course and utilityrent bills paying housing, finding appropriate including living and often resorted a variety to of strategies, and aunts households with parents, in multigenerational Virtually all unmarried and older married siblings. uncles, Married or other relatives. parents with live men and women elderly take in their or widowed to also often have Egyptians refugees, to in contrast and supportparents However, them. to able were study this interviewed for Egyptians some government, the Egyptian housing from obtain subsidized rent-free and others lived flats controlled in rent some lived family-ownedin apartmentor houses Several buildings. in the working lived class respondents of our Egyptian in government-built neighborhood Al-Ala of Bulaq Abu neighborhood also included The apartment buildings. in abject lived poverty. a slum section Egyptians where and and the low- of Egypt residents long-time refugee Yet likely much more interviewed were Egyptians mid-income rent- form of a rents,” “old from benefit to or their flat own to certainfor Among fixing long-time apartmentresidents. their own the most likely to were Palestinians the refugees, For families who apartments. in fixed-rent homes or live “old these apartmentsame the in decades, lived for have friends or relatives. While sharing housing helps refugees sharing helps refugees housing While friends or relatives. overcrowding. also lead to it can of rent, the cost reduce in interviewed live often to chose refugees African The other or co-nationals and near churches to close proximity communities. their refugee for gathering places common neighborhoods affluent more the to move afford could Few in more especially if they worked on the outskirts of Cairo, could costs commuting since neighborhoods, Cairo central Somali Ethiopian, and For earnings. meager deeply into cut working women as domestic laborers, Sudanese refugee households is a key consideration. their employers’ to proximity for their difficult it was that complained refugees All refugee Many outside of the house. socialize to children to children for unsafe it was that fears mothers expressed be subject would to their children or that outdoors play of race. or discrimination, especially on account harassment Vitamin D from suffer children refugee many Worryingly, for prolonged deficiencyto being kept inside the house due whose mothers children for is worse problem This periods. and a lack of affordable Due to outside the home. work a lack of a familial network and to childcare adequate their children must leave mothers many childcare, provide (Briant and Kennedy 2004). home while they work locked at in with non-relatives (only two interviewed two (only reported non-relatives in with while most sharing their apartment a non-relative), with sharing housing with interviewed were refugees African 21 Other Refugees

often used these contacts to help locate neighborhoods locate help oftencontactsthese used to Iraqis usually did not move or apartments live. in which to In general, few refugees have established networks to established networks to have refugees few In general, Those housing. to share finding housing or facilitate Egypt in already friends relatives or have did who refugees of their rent with the help of cash assistance from Caritas. Caritas. from with the help of cash assistance of their rent 300EP (approximately $50). All refugees paid a rough rough a paid refugees All $50). (approximately 300EP utilities in addition $16) for of 100EP (approximately average least a portion at interviewed paid for refugees Many rent. to similar range for rent (600EP to 2000EP), but that they were they were but that 2000EP), (600EP to rent for similar range roommates between rent their divide to likely more much only approximately for responsible was each resident so that rents ranged widely from 600EP to 2000EP, with variations with variations 2000EP, to 600EP widely from ranged rents furnished. and whether or not it was size location, due to Only one Iraqi their flat. family interviewed owned Of the they paid a that indicated non-Iraqis refugees interviewed, metropolitan Cairo. However, a survey of rent costs among among a survey costs of rent However, Cairo. metropolitan household the average that 28 Iraqi households indicates though of 1,153EP on rent, interviewed an average spent to pay for the same basic needs (WHOneeds basic same the for pay to 2009). MOH and households is too of Iraqi refugee sample size The in the greater about housing costs generalize small to 2008, 77.2 per cent of Iraqis needed to borrow money to money to borrow of Iraqis needed to 2008, 77.2 per cent (WHO or rent food 87.1 for pay and MOH 2009). Likewise, money borrowed households refugee of African per cent for rent, medication and education fees, and were thus and were fees, and education medication rent, for seeking looking moving, family budgets by adjust their to In out of school. or pulling children less medical treatment be changing, however, as Iraqis have depleted their savings their savings depleted Iraqis as have however, be changing, interviews, In situation. several refugee in this protracted pay to afford longer no could they that Iraqisindicated was a more extreme example of the general trend among trend of the general example extreme a more was apartment and size prioritizeneighborhood Iraqissafety, to appears to trend This and protein. furniture amenities over of 6th of October City. Despite its size, the apartment its size, had Despite of 6th of October City. the offered hostess the refugee When almost no furniture. the woman that a small snack, revealed it was researcher particularThis instance had very in her home. little food necessarily signify financial affluence. In one striking financial affluence. signify necessarily airy a large, four- into invited was a researcher example, apartment bedroom area of an Iraqi living in a nice who was Internet undoubtedly mitigated some of the boredom some of the boredom mitigated Internet undoubtedly Cairo. in life refugee with often associated isolation and not did items these of presence the time, same the At as status-markers of their middle-classtheir of status-markers as in backgrounds the quality of their children’s improve to Iraq or in order and Television of a computer. with the provision education number of beds for each family member, a TV, a computer a computer TV, a each family member, number of beds for Iraqi families with Internet conditioner. and an air perhaps comforts, prioritize these creature to appeared apartments, while others resided in more spacious in more apartments,others resided while Iraqi All suburbs. apartments of Cairo’s areas in the nicer sufficient a afford to able interviewed were we families far from Cairo’s city center and, consequently, far from many many far from consequently, and, city center Cairo’s far from services NGO office. and the UNHCR-Egypt of the centralized modest furnished, in sparsely Some lived Iraqi refugees perception of safety. The downside of this choice, however, however, this choice, of downside The of safety. perception other Heliopolis and Rehab City, 6th of October, is that middle-class located Iraqis are by neighborhoods favored its more spacious residences, proximity to schools and and schools to proximity residences, spacious its more

CH3: Refugee Livelihoods Refugee

CH3: Refugee Livelihoods Of the poor and working-class Egyptians interviewed, three are expected to continue living with their parents until lived in family-owned apartments, one benefited from marriage, and some even continue to live with their families the “old” fixed-rent system, several lived in government- after their weddings as well. Egyptians thus can benefit subsidized or –built homes, and only a handful indicated from a number of social and institutional safety nets to that they paid above 1000EP per month (whereas Iraqis’ acquire affordable housing that are out of reach for refugees. average rent cost was 1100EP). Furthermore, adult children

Refugee Livelihoods 3.6 Recommendations CH3:

Refugees in Cairo are economically, politically and culturally and the urban environments examined by the authors tied to the larger urban community, therefore their livelihoods of these reports—i.e. , Uganda, Johannesburg, are inextricably interdependent on local relationships and South Africa, New , India—is considerable, primarily processes. Refugees, particularly less educated African because of Egypt’s reservations to the 1951 Convention refugees, face similar challenges as the urban poor, including on article 24 (labor legislation) and resulting lack of rising unemployment rates, insecure housing access, lack of refugees’ right to work legally in the country. However, social safety net compounded with barriers such as racism, we have consulted both reports as we analyzed our discrimination and insecure legal status, which make them own data and compiled resulting recommendations. more vulnerable to exploitation and marginalization. Cognizant that the bar on legal employment coupled with The problem of refugee livelihoods is compounded by Egypt’s the extremely high unemployment rates in the country pose high unemployment rates, for citizens and refugees alike. The significant barriers to refugees’ labor force participation, Egyptian Government’s Office of Statistics placed the official adversely affect refugees’ livelihoods and impede self- unemployment rate at 12.4 per cent at the end of 2011 reliance, we suggest that UNHCR and BPRM and their (CAPMAS 2012). Unofficially, most experts suggest that the implementing partners consider the following strategies: real unemployment rate is double or triple the official statistic, and underemployment is a pervasive problem. Even using the Access to Employment government’s data, however, it is clear that unemployment • Advocate with the Government of Egypt to extend has risen still higher in the aftermath of the 2011 revolution. the right to work to all refugees. We recognize that Ethnographic data from interviews suggests that refugees this is a long-term goal and might require changes in as well as poor working class Egyptians struggle to the Egyptian labor legislation. However, as the new establish sustainable livelihoods. Refugees who are able to Egyptian government is considering many political work depend mainly on unstable and irregular earnings; and social changes, it might be an opportune time to many work as domestic workers. Refugees working in open discussions on strategies to reduce impediments the informal economy are exposed to numerous risks for securing work permits and expanding employment and abuses. At present, there are no mechanisms to opportunities for refugees and asylum seekers. monitor refugees work conditions. Given the state of • As an intermediate step, the Government of Egypt the economy in Egypt and the staggering 40 per cent should consider expanding refugee employment unemployment rates, there are insufficient opportunities opportunities in the sectors with insufficient labor for safe and dignified employment for refugees. supply or in industries where Egyptian citizens do not Without legal access to employment opportunities, want to work for religious or other cultural reasons. refugees in Cairo will not be able to support themselves and • Build in protective elements into economic will have to continue to rely on costly international aid and programs. Egyptian refugee policies—lack of right charity. There is a need to develop self-reliance programs to work—severely impede refugees’ ability to pursue for both the local poor and refugees. We are cognizant livelihoods. However, local authorities “turn a blind that this is a long-term goal. In the meantime, there is eye” and tolerate refugees involvement in the informal also a need to implement creative strategies aimed at economy. Efforts to protect refugees working in the enhancing urban refugees’ self-reliance more immediately. informal economy should be explored. Protective CH3: elements—such as accompaniment, requiring codes BPRM has recently commissioned two studies on achieving Livelihoods Refugee urban refugee self-reliance. One of the studies has been of conduct for employers, sensitization campaigns, carried out by the Women’s Refugee Commission (2011) linkages with local women’s leadership and political and resulted in two reports: Dawn in the City: Guidance for groups—should be built into economic development Achieving Urban Refugee Self-Reliance and Bright Lights, efforts in order to ensure protection and safety Big City: Urban Refugees Struggle to Make a Living in New of refugee workers, particularly refugee women. Refugee Livelihoods Delhi. Karen Jacobsen has also written extensively on • One program in Cairo trains refugee women as Refugee Livelihoods refugee livelihoods, including in her book The Economic domestic workers, and staff accompany them CH3: Life of Refugees (2005). All three of these publications make on the first day of their jobs. The NGO staff act CH3: many creative recommendations regarding urban refugee as witness to the agreed employment terms, livelihoods. However, the difference between Cairo, Egypt including compensation, letting the employer

22 CH3: Refugee Livelihoods CH3: Refugee Livelihoods We UNHCR Despite Despite Since most jobs available to refugees refugees to most jobs available Since . Basic banking and budgeting. Many families Basic banking Many and budgeting. project, talked of this interviewed in the course send children enough money to about not having Some of meals a day. them three or feed school to budgeting. from poor result may these difficulties With funding from UNHCR, the Coptic Coptic the UNHCR, from funding With Social Services for Organization Evangelical development an economic ran (CEOSS) included program This refugees. for program placement job and training vocational the 2008, to 2007 From components. per cent (43 300 refugees trained program 94 participantsplaced and female) in jobs consultants Specialized upon graduation. conducted in areas market assessments The selected labor demand. with identified embroidery, sectors—medical care/nursing, computer enterprise, Internet-based others—eitherand not maintenance did could permits work the or work require CEOSS be performed homes. in refugee with Egyptian relationships developed for “job bank” a create to in order employers (Adapted of the program graduates referring 2008). Refugee Commission Women’s from • in Cairo. Refugees work in formal and informal jobs, jobs, informal and in formal Refugees work in Cairo. mainly in cash without few remunerated but are encourage We of money paid and owed. records partners implementing BPRM and UNHCR organize to including: financial literacy programs, training informal economy informal efforts be undertaken should economy, in the informal are is necessary kind training assess what to to of vocational in the informal of workers and safety protection ensure both should focus programs training These economy. safety. as occupational on skill as well development niche identify to analysis labor market Conduct opportunitiesrefugees. employment for fund a labor BPRM and UNHCR to encourage sectorsto identify effort market analysis in order fill be able to might refugees and industries where has a robust Egypt example, For labor supply gaps. industry tourist and restaurants as jobs—such with is served—thatnot always alcohol are where cruises observant Christian suitable for Muslim Egyptians. gaps. fill in these labor to be trained could refugees aspiring entrepreneurs. for training Organize partnersand BPRM implementing should explore the possibility aspiring entrepreneurs of training business partnerships governing on local laws projects incubation citizens, Egyptian with partners. of different responsibilities and fiscal financial literacy programs. Promote work do refugees many restrictionsemployment, on be expanded to all refugees. Promising practices Promising all refugees. to be expanded should past the in funding UNHCR with implemented an example]. for below [see and expanded be assessed in necessary work training to on vocational Focus the past some attempts to provide vocational training training vocational provide to attempts some the past been implemented. had of refugees group a broader to opportunities training vocational that recommend We • • • • 23 Currently, Currently, Stakeholders Stakeholders Track refugees’ refugees’ Track

The government previously previously government The . Monitoring child labor to ensure that youth youth that ensure Monitoring child labor to activitiesengaged in economic them can combine pursuits. with educational Counseling on forced and exploitative labor, labor, and exploitative on forced Counseling rights. on workers’ including training to be outside late at night, unaccompanied or unaccompanied night, at be outside late to with and other small spaces in back rooms work is room there the same time, At male colleagues. the for lobby NGOs to and UNHCR-Egypt for and to respond better to of Egypt Government and other GBV. harassment sexual prosecute to protect refugee women from gender-based gender-based from women refugee protect to to consulted be should Women job. the on violence scale assess the GBV, to their vulnerabilities identify these mitigate to devise ways and of the problem programs placement job NGO example, For risks. opportunitieson finding employment should focus them will not require that women refugee for know that the woman has a support has know the woman that network. all in upon be expanded should model This sectors. economy informal relevant of the majority workingThe of refugees as domestic be taken to needs Care women. are workers • • • training, except for voluntary returnees. However, in However, voluntary returnees. for except training, Expand economic development programs. programs. development Expand economic vocational does not allow of Egypt the Government could be used to alleviate these problems: alleviate be used to could in negative economic strategies such as eating such as eating strategies economic in negative living and selling household assets, meals, fewer and pulling relationships working in exploitative strategies following The out of school. children Address negative economic strategies. strategies. economic negative Address families engage some refugee that indicated force participation interview an intake to when refugees force UNHCR assistance. a particular for to come program collection this data effort. coordinate need to would desire to improve monitoring and evaluation of refugee of refugee and evaluation monitoring improve to desire on self- tracking rely Employment would livelihoods. accomplished easily reporting;relatively be could this and labor questions about employment adding a few by footholds in the economy in order to tailor training and tailor training to in order in the economy footholds with activities be consistent These would advocacy. and a on livelihoods guidance 2011 operational UNHCR’s should be explored anew with the new government. anew with the new government. should be explored of refugees. employment Track gained they have understand where to employment However, such a scheme would allow refugees of all refugees allow such a scheme would However, support small opening to nationalities by themselves and the topic and other typesbusinesses, of stores microcredit enterprises microcredit implement permission to denied UNHCR-Egypt developed. they had enterprise a microcredit maintaining employment, advising on upward mobility advising on upward employment, maintaining refugees. hire to employers with and advocating allow to government with the Egyptian Work Once the barrier to legal employment is lifted, is lifted, the barrier legal employment Once to advocates/ employment should hire programs in finding and assisting refugees job developers Create an employment advocate/job developer. developer. advocate/job an employment Create

• • • • •

CH3: Refugee Livelihoods Refugee

CH3: Refugee Livelihoods • Simple accounting involving keeping track each other’s homes under the supervision of a skilled of hours worked and payment owned. contractor or landlord. In-kind contribution of labor to beautify dwellings could serve to offset housing costs. • Financial planning. Many refugee households manage their cash flow from day-to- • Organize training programs on household management. day without planning for future needs, Some of the refugees residing in Cairo came to the city such as rent, utility bills and school fees. from rural areas and might need help in adjusting to living in apartments and sharing communal space with others. Housing Financial Stability Education • UNHCR should monitor housing options for CH4: Refugee Livelihoods refugees to ensure that discrimination by nationality, • Assessment. Conduct an assessment of the level ethnicity, religion, gender or other factor is not of income needed to survive in Cairo and use CH3: limiting services to Iraqi and other refugees. this information to devise an updated formula to calculate cash assistance to refugee families. • UNHCR and BPRM should lobby the Egyptian government to allow refugees access to rent-controlled • Means and Assets Test. Institute a means and assets housing options or provide housing subsidies. test to determine who qualifies for cash assistance. This test should take into account income from properties • The Egyptian government should negotiate with socially in Iraq and remittances received from family and minded landlords to set aside affordable housing units friends. This strategy requires a good reporting system. for the poorest refugees. Muslim or Christian charitable organizations, churches and may also be • Social security. Work with the Governments of Egypt suitable partners for providing subsidized housing or and Iraq to develop a social security system for refugees donated furniture to refugees. Zakat, or tithe, a practice too old or disabled to work. The Government of Iraq of giving a fixed portion of one’s wealth to charity, could transfer retirement money to UNHCR-Egypt generally to the poor and the needy, is well known and or directly to the Government of Egypt. Distribution practiced both in Islam and Christianity. This practice of these funds could be done through a debit card. A should be explored in terms of providing cheap housing, social security system administered by the Government donation of furniture and other housing equipment. of Egypt has several benefits; it would: increase the reliability of cash assistance for permanently needy • BPRM and UNHCR implementing partners refugee families, facilitate the integration of refugees should organize training programs on housing into mainstream Egyptian institutions, and lighten laws, tenant rights and lease negotiations. the responsibilities of Caritas in providing monthly • NGO advocates and/or legal aid workers should cash assistance to a wide number of refugees. review housing leases on refugees’ behalf and We encourage UNHCR to set up a demonstration accompany refugees to sign leases in order to project that would test some of these strategies. ensure that they are entering into a fair agreement. • Transparency. Whatever strategy gets implemented, • UNHCR and BPRM implementing partners UNHCR must be very transparent about eligibility should set up committees to monitor housing for cash assistance and/or social security. At the conditions. These committees should include moment there is too much confusion about eligibility representatives of NGO and refugee communities. criteria for any type of cash assistance, the duration These committees would be particularly important of eligibility and the schedule of disbursement. in neighborhoods with substandard living • Financial services. For poor refugees, borrowing conditions where structural problems in apartment money further increases their vulnerability. Formal building might create dangerous living conditions or informal saving schemes can guard refugee • Improve housing conditions through sweat equity families against income shocks. UNHCR and BPRM and mutual self-help programs. What refugees implementing partners should explore establishment do not have in financial resources, some have in and training for small savings and credit programs determination and willingness to work hard. Mutual akin to the Grameen Bank or self-help groups set up self-help housing programs could bring together by ILO for poor residents of developing countries. groups of refugees to help renovate and maintain CH3: Refugee Livelihoods Refugee Refugee Livelihoods CH3:

24 CH4: Education with disabilities allowing them to attend specialized specialized attend them to with disabilities allowing parent, reportedan Egyptian as by However, classes. Egyptian in exist do not programs education special equipped to schools are Some private public schools. services with learning specialized children to provide very are but these schools illness, disabilities or mental or support does not subsidize “the state and expensive said a mother of a child with disabilities. the disabled,” education grants (Roman 2009). Catholic Relief Services (Roman Catholic 2009). grants education grants 7,000 approximately provide to continued has numbers These study. the time of CARIM’s annually since urban number of the estimated to seem small in relation stipends educational However, living in Cairo. refugees with registered are who refugees to only distributed are not do refugees many before, indicated As UNHCR-Egypt. information registration because refugee register to want do who refugees government, with the Egyptian is shared 2004 prior who arrived to refugees African Many not trust. in remained but have UNHCR-Egypt by not recognized were migrate to because they want Others do not register Cairo. country; another to because they Iraqis do not register many back and forth between preserve the ability to travel to want to not eligible are refugees Palestinian and Iraq. Egypt or with Refugees registered not UNHCR-Egypt. with register barriers access to greater face UNHCR-Egypt by recognized with UNHCR-Egypt. than those registered education to where Jordan, from very is in Egypt the situation that different school system. the Jordanian into mainstreamed are refugees children for money voucher additional provides CRS widely known or clearly understood by many local teachers, teachers, local widely known many by clearly or understood a result, As stakeholders. and even school administrators any in schools for been implemented has rarely the decree differences, cultural Language barriers, population. refugee and differences of discrimination or harassment, experiences of origin in their countries schools refugees’ in curricula from refugee mainstreaming obstacles to formidable also present the Furthermore, public schools. Egyptian into children restrictions has still maintained on the rights of government secondary public attend to or universities. schools refugees barrier to quality significant education is the second Cost and private Public and refugees. Egyptians both for and extra-curricular uniforms books, for fees schools have often far beyond are fees school tuition Private lessons. communityrefugee advocate A afford. can refugees what only one child enroll to forced some families are said that home, at of their children in school while keeping the rest education. cost of private the because they cannot afford Relief Service the Catholic the time of our research, At 6,000 approximately to grants educational provided (CRS) A study carried CARIM (Consortium for out by children. that indicated Migration) on International Research Applied children, 2007/2008 some 6,900 refugee in the school year UNHCR-Egypt received including 2,621 Iraqi children, Education 25 Access to Primary to Education Access 4.1 Chapter 4: Chapter year 2007/2008 a total of 4,209 Iraqi children Iraqi4,209 of children total a 2007/2008 year emic

$275 per child per year. The education vouchers can also be can vouchers education The $275 per child per year. It and books. is noteworthy school fees uniforms, used for $300 to $700 per year. UNHCR-Egypt offers education grants grants education offers UNHCR-Egypt $700 per year. $300 to all of do not cover but these grants refugees, registered to $130 to from range grants education refugee tuition costs: education, 3,903 Iraqi children attended private schools private attended 3,903 Iraqieducation, children public schools (Roman 2009). and only 306 attended from ranging rates, tuition high have Egypt in schools Private were enrolled in private primary private in enrolled secondaryand were schools. structural because of the detailed limitations Yet, higher quality private for preference and Iraqis’ above According to the Egyptian Ministry the Egyptian to in the of Education, According acad that the Minister of Education granted all refugees the right the right all refugees granted the Ministerthat of Education public primary attend to schools in 2000, this right is not only enroll in public schools if they are legally recognized legally recognized in public schools if they are only enroll including birth documentation, extensive and can provide the fact Despite UNHCR-Egypt. certificates from and letters 9,000 school age refugee children in Cairo. There are two two are There in Cairo. children 9,000 school age refugee First, structuralmain barriers education: and social. to Refugees can obstacles. bureaucratic numerous are there phase. The great majority of students in Egypt from the majority from in Egypt of students great The phase. primary tertiary to in public institutions. enrolled are levels approximately are there service to providers, According preparatory stage, secondary stage, preparatory post-secondary and education The is compulsory of age. Education education. 15 years until compulsory the preparatory applies only to free law education of the average Egyptian family’s budget (Hartmann 2008). family’s Egyptian of the average and is is highly centralized system educational Egyptian The primary which comprises basic education, divided into and of elementary take in the students school and preparatory not only much of the consume afternoons and evenings, part time but also a substantial spare and teachers’ students’ outside of the official classroom, either at home or in private in or home at private either classroom, official the of outside which the majority lessons, private These centers. tutoring number a large and even high school students of Egyptian system” of private supplementary tutoring has evolved on supplementary of private has evolved tutoring system” Today, control. of state and out of the reach level the informal parta large of instruction takes place and learning in Egypt simultaneously in Egypt: on the official or formal level, a formal level, on the official or Egypt: simultaneously in being are universities and schools private of number growing education “shadow the same time a while at established, the last decades, the qualityof state-provided servicesthe last decades, of education provision the a result, As has deteriorated. The actors. non-state by taken over been has increasingly takingis education of levels two on privatization place CAPMAS, 43.5 per cent of the population (approximately (approximately of the population 43.5 per cent CAPMAS, 20 (CAPMAS of the age below currently are million) 35 duringrisen steadily have rates enrollment While 2012). the public education system has been struggling to has been struggling to system the public education numbers of students. increasing rapidly accommodate agency statistics government’s the Egyptian to According guaranteed to all Egyptian citizens since President Nasser’s Nasser’s President since citizens all Egyptian to guaranteed high to due However, 1950s. the in reforms socialist resources, lack of financial and rates growth population In Egypt free and equal access to education has been education to and equal access In free Egypt

CH4: Education

CH3: Refugee Livelihoods Iraqis hand, she also shared a disturbing story with us regarding Iraqi students. At the time of our interview in the winter of Iraqis have a strong preference for private schools at all levels 2010, Iraqi students constituted about 10 per cent (or 200 of education; a preference that is also shaped by the fact that students) of the school’s population. Four years prior to our most Iraqis cannot or believe they cannot enroll their children research, in 2006, there were about 700 Iraqi children in this CH4: in public schools. Most of the Iraqi families we interviewed in particular school, but the principal received an order from the course of this project did enroll their children in private the security forces not to accept any more Iraqi children Education schools, despite its significant cost. They spoke about because there were too many Shi’i students in the school. Education Education Egyptian public schools with disdain—as did many Egyptian The Egyptian pupils come solely from Sunni families. When families—and in many instances were disillusioned with asked what happened to the 500 students she said that CH4: CH4: Egyptian private schools as well. Iraqi parents put a premium some graduated, some returned to Iraq, some were resettled on good education. Most are well educated themselves and in the United States and Canada, and some left the school want their children to receive an equalivalent education. because they could not afford the tuition any longer. We Service providers remarked that Iraqis feel their children wondered if the last cohort left the school because of the are entitled to good education. This feeling of entitlement opposition of the Security Services to the Iraqis’ enrollment. seems to be related to the fact that education was free in Iraq. Iraqi students face several challenges in Egyptian schools, One Iraqi father said he had three sons in private schools particularly if they arrive in the middle of a school year. to the cost of 1,700 EGP, or $280, for each one. Although School curricula are not compatible, and the difference in the he received 2,000 EGP ($328) in educational vouchers per Arabic spoken in Egypt and that spoken in Iraq contribute to child, he found it inadequate to cover all the additional some difficulties. Egyptian children start learning English in costs such as uniforms and school fees. In a private middle Kindergarten or the first grade, while Iraqi students begin school we visited, tuition was 2,200 EGP ($360) per year. to learn English in fifth grade. Overcrowding of Egyptian The principal estimated the cost of books at about 65-120 schools severely limits refugee children’s access to education. EGP ($10-$20), depending on the grade level. Uniforms cost In December 2006, dozens of Iraqis protested in front of the 85 EGP ($14) per outfit; most students need two uniforms. Ministry of Education when their children were expelled from Refugee students who received educational stipends from school because their visas were no longer valid (Roman 2009). UNHCR-Egypt had to pay the tuition upfront and then Similar complaints have been heard among Iraqi refugees go with the receipt to UNHCR-Egypt or CRS to receive in Jordan, who also struggle to adjust to the differences their stipend. Parents indicated that it sometimes posed between the Iraqi and Jordanian curricula (Davis 2012). a burden on them, as they had to wait to be reimbursed, often for several days or weeks. This particular school did Africans not offer scholarships or financial aid to any students, Egyptian or Iraqi. However, the principal mentioned that Sudanese refugee children can, in theory, exercise their occasionally a rich benefactor supports some students. A right to public education under the Four Freedoms few months prior to our research, an Iraqi businessman agreement as well as under the 1992 and 2000 Ministry gave each of the 220 Iraqi students 500 EGP ($80). of Education decrees. However, in practice, the extreme population pressure on Egyptian schools and the extensive Parents also talked about the need to augment the documentation—birth certificate, last school certificate, education that children received in schools with private identity documents with legal residence permit and a letter tutoring. As already mentioned, private tutoring is from the Embassy of Sudan—required to enroll a refugee ubiquitous in Egypt and is largely seen as a requirement child in school, severely limit refugee children’s access to for students to satisfactorily pass annual examinations. public education. Refugee children and adolescents with The cost of private tutoring is not insignificant—anywhere rejected asylum claims constitute the most vulnerable from 10-100 EGP (or $2-20) per hour depending on how group without any hope to access free public education. many subjects the tutoring sessions cover. Teachers expect that children will be tutored in several topics at least once According to community members, racial prejudice poses or twice a week. The costs add up. On the other hand, an additional barrier to education for African refugee it seemed that teachers insist on the need for private children. Given tensions between African refugee and tutoring because they want to make additional money. Egyptian children in schools, UNHCR-Egypt funded a special program helping students from different backgrounds get Since almost no refugee students are able to afford the to know each other. Classmates participated in artistic and exorbitant costs of attending university, families must make musical activities and talked about their lives and hopes difficult decisions, weighing the relative benefits of setting for the future. No formal evaluation has been conducted of aside a significant portion of the household income to pay the program; therefore, while it is difficult to say with any extra costs for education. Based on our interviews, many certainty how effective this strategy is, it appears promising. Iraqis are still expecting to be resettled internationally, and thus they invest in their children’s education with the hope Most Sudanese refugee children attend so-called “Refugee that they will continue their studies abroad. The same is not Schools,” created and run by Sudanese refugee communities necessarily true about African students (see discussion below). in Cairo. These schools are often affiliated with churches, much cheaper than private schools, and located closer to where Reports about tensions between Egyptian and Iraqi students refugees live. Africa and Middle East Refugee Assistance were rare. A principal of a private primary and middle school (AMERA) reported that the situation in these schools has in 6th of October reported only one incident of a fist fight been improved recently by the introduction of the Sudanese that erupted between a Sunni Egyptian and a Shi’i Iraqi boy curriculum allowing students to receive accredited diplomas. over a difference in interpreting a call to prayer. On the other In the last two years, Sudanese students have been allowed

26 to take the Sudanese university entrance exams by paying options exist for Sudanese refugee children living in Cairo. $50 to the Sudanese embassy. Other African refugees from Eritrea, Somalia and Ethiopia also attend refugee schools, According to our interviews, very few Somali or Ethiopian usually attending those run by the Sudanese since these are refugees benefit from church-based educational programs offered in Cairo. Self-help schools organized by the CH4: the largest and best organized. There are also Somali refugee CH4: schools, but these have been plagued with organizational Somali community in Cairo provide an alternative for a Education and administrative problems. It is unclear whether the 2011 small group of Somali children, though many go without Education secession of the Republic of South Sudan from Sudan has education altogether and stay at home while their parents

Education impacted this arrangement. Generally speaking, we did not seek work. Ethiopians have fewer options still. According hear very favorable assessments of these schools. Parents to researchers, a large number of Ethiopians in Egypt CH4: and volunteer teachers alike bemoaned the fact that these have rejected refugee claims or have been reluctant to schools do not have the capacity to prepare students for approach UNHCR-Egypt for refugee status, and thus live further educational pursuits. According to some reports, in Egypt illegally. Legal vulnerability, social instability, only one of these primary school programs teaches the language barriers and perceived racism in Egypt have Egyptian Curriculum. One father said that the teachers all acted to inhibit Ethiopians from forming community- are often barely literate themselves and do not have any based organizations and schools. In interviews, Ethiopians pedagogical preparation. One mother suggested the and Somalis were the least likely to attend school and the schools “warehouse” students, but quickly added: “It’s better most likely to report extreme anxiety and social isolation. than having the children roam the streets and get in trouble.” For the African refugees who have had their applications Many Sudanese families expect to be resettled in the United for resettlement rejected or who have decided to remain States and prefer to send their children to schools where in Egypt indefinitely, there are fewer perceived benefits English is the language of instruction. Southern Sudanese to continuing to pay education fees for their children, favor English language schools because of their past especially beyond primary school, which explains in experiences in Sudan and their rejection of the Arabization part the lower percentages of enrollment for Sudanese, of instruction that took place after 1989 (Peterson 2001). Somali and Ethiopian children (although linguistic The Sudanese value education and see it as the only and cultural barriers also play an important role). way out of poverty for their children. Unfortunately, few 4.2 Access to Secondary Education Refugees are prohibited from attending public high schools; to enroll in secondary education programs. Economic as a result, any refugee desiring to attend high school factors also pose a barrier: the relative and absolute poverty must attend a private or refugee-run school. CRS provides of many African refugee individuals and households pushes educational grants to refugees of any nationality to help many adolescents to seek work rather than education. offset the tuition and uniform costs. Iraqi adolescents generally attend mostly private high schools with the Palestinians support of CRS grants. Secondary education is virtually Between 1960 and 1978 Palestinians had the same right to inaccessible to most African refugee youth for logistical public education as Egyptians. Political events in the late reasons: refugee-run schools often do not follow the 1970s “marked the end of the golden era for Palestinians Egyptian curricula, and thus their students do not take the in Egypt” (El-Abed 2005). After an assassination attempt required annual examinations necessary to enter high school. on an Egyptian minister by a Palestinian group, Egyptian I dropped out of high school because of the laws and regulations were changed to take away the rights problems in Ethiopia. And here I don’t have much to education, employment and residency for Palestinians. opportunity for education. Even if I got a chance A Palestinian woman shared her story of being expelled from to study I don’t think I would be able to learn a public high school and forced to go to a private one to finish because I have a lot of stress. I am always worried her secondary education. Her two adolescent children go to and depressed about my life here and about my a private Egyptian high school; she pays 3,000 EGP ($495) future. One needs to have a clear mind to learn. per year for each child. Another Palestinian woman told us Plus I do not have money for tuition and transport that she and her older brother attended an Egyptian public so I don’t even think about learning at the moment.” school for several years until someone found out that they An Ethiopian youth were Palestinian and had them thrown out of school. “I don’t know,” she said, “how we were able to slip through the system Since most African refugees attend these informal schools for as long as we did.” She indicated that her father might have rather than private Egyptian primary schools, few are eligible bribed a school official when he signed them up for school. 4.3 Access to Higher Education Public higher education is free for Egyptian citizens. Private Egyptians commented on the exceptional quality of university education is much more expensive. Major government-supported universities while stressing that universities include Cairo University, Ain Shams University, these public institutions of higher education are becoming Helwan University and the 1,000-year-old Al-Azhar University, increasingly more expensive. Egyptians also despaired one of the world’s major centers of Islamic learning. Several that, with the exception of the American and the German

26 27 Universities in Cairo, colleges do not provide students of the U.S. refugee resettlement system on attaining early with practical skills suitable for the modern job market. economic self-sufficiency. Many Iraqi parents and youth were alarmed by reports coming from friends and relatives resettled Many service providers indicated that access to higher in Dearborn, for example, about the need to undertake education was a real problem for all refugees, including employment, often not commensurate with their education CH4: Iraqi households with relatively ample household wealth. and/or aspirations, instead of pursuing college degrees.

Iraqi college students are treated as foreign students and Education charged foreign student tuition, which often has to be paid It is very difficult for African refugees to be eligible for university

in U.S. dollars. Service providers did not seem to have a good and harder still to afford attending institutions of higher Education Education understanding of the tuition costs; they mentioned rates of learning. A new law recently granted Sudanese students CH4: CH4: 15,000-20,000 EGP ($2,400-3,200) per year, while refugee the ability to enter Egyptian universities without first taking parents suggested that tuition averages over twice that: the national exam administered to all secondary students in 40,000 EGP or $7,000. One Iraqi father said that although Egypt. This is a positive development, and refugee schools his son was the smartest in his class, he has no prospects are now focusing on helping Sudanese students graduate for further education, as the family cannot afford college from high school so that they might be eligible to attend. tuition. “He just sleeps all day,” the father said concerned However, due to the low quality of refugee schools many that his son is slipping into depression. A small number of Sudanese attend, it will take time before large numbers of families reported to our researching team that they sent Sudanese youth are truly prepared for a university education their college-aged children back to Iraq alone to finish in Egypt. Beyond this, it is unclear how refugee students their university degrees, despite the safety risks they faced. would be able to afford the fees of Egyptian universities. In addition, non-Sudanese refugees are not covered by The high cost of college has influenced this new law; they would first need to take the difficult Iraqi refugees desire to resettle in the West. College-aged entrance exam before applying to universities. Even if they Iraqis we spoke with expressed a preference for settling in found financial resources—a very unlikely proposition— Europe or Canada, as they were aware both of the high cost they would not be able to pass entrance examinations of college education in the United States and the emphasis since, by and large, they do not attend accredited schools.

4.4 Recommendations

Although UNHCR’s Urban Policy (2009) states that when educational shortcomings. This is a prime time to make new working in urban areas, UNHCR will avoid the establishment recommendations to improve refugee education and take of separate and parallel services for refugee beneficiaries, advantage of this momentum and progress in education. parallel educational structures do exist in Cairo. There are currently three different types of educational structures that In the short-term there are smaller, practical steps that refugees access: public Egyptian schools, private Egyptian can be taken to provide and/or improve the quality of schools (often with stipends from CRS) and refugee schools education to meet the needs of Cairo’s refugee children. run by the community with various kinds of assistance from • Streamline School Admission Requirements. The UNHCR-Egypt and its implementing partners. Each type Ministry of Education should lift the requirement of educational system facilitates access to education for to provide school records in order to admit refugee refugee children and fulfills the needs of Cairo’s different children to school. Placement tests and an interview refugee populations in varying ways. For UNHCR-Egypt with parents or guardians should be sufficient. to achieve its goal of mainstreaming refugee students, dramatic changes would need to take place to dismantle • Capacity Building. Capacity building should be a key these parallel systems. On the macro-level, UNHCR-Egypt priority for stakeholders and development agencies will need to continue to push the Government of Egypt to working with refugee education in Egypt. Egypt’s public clarify the right of refugee children to attend schools and school system suffers from overcrowding, few quality to train local schools on these policies. As opportunities to checks, and an emphasis on rote memorization. Low attend public schools widen, CRS will need to reduce its teacher salaries encourage the growth of a private support for private schools except for those children who lesson industry that has become all but required for are legally or otherwise unable to attend public schools. students to pass exams. Capacity building projects in the public school system can benefit both the local UNHCR has listed Egypt as one of its 13 “priority countries” population and the refugee population if the rights of for education for 2012-2016. During these years, UNHCR refugee students to attend public schools are clarified. will work to develop “multi-year, multi-sectoral educational strategies” to improve the instruction and protection • Trainings for Egyptian Teachers and of refugees that have suffered from a lack of quality, Administrators. Local teachers need to gender equality, geographic location and operational understand legal rights of refugee students setting. UNHCR will provide training, technical assistance, to attend Egyptian schools. Rights training monitoring and evaluation, advocacy, fundraising, data along with cultural sensitivity trainings will collection and capacity development to Egypt to address facilitate refugees’ access of existing educational

28 CH4: Education Our research Our research As indicated, Egyptian Egyptian indicated, As BPRM and UNHCR-Egypt UNHCR-Egypt BPRM and schools are extremely overcrowded. BPRM ought to to ought BPRM overcrowded. extremely schools are and development and other donors with AID consult and actorspossibilitythe on resources joining of school existing schools or expanding building new population the growing accommodate to buildings children. refugee and local both students, of to pay out-of-pocket for these services. these out-of-pocket pay for to Schools. Additional Build • Involve UNICEF. Involve their regarding UNICEF with should consult qualitythe education of improving in involvement children. refugee both local and for in Cairo Refugees. Adult for Training Additional lack basic financial and adults refugee that indicates literacyhealth knowledge well and skills. are INGOs classes these adult educational provide positioned to These adults. refugee as African Iraqi as well for value, not only an educational have classes would would promote benefits; they but also psychosocial Members of and community-building. socialization as health trained be could communities refugee the them providing counselors, or financial advocates with practical skills benefit them whether would that or locally integrated. returned resettled, they were • • 29 Highly-educated There are also many also many are There CRS should consider CRS should consider refugee adults to provide tutoring to refugee refugee to tutoring provide to adults refugee in private enroll expected to who are children have and whose parents sessions tutoring should be provided with the opportunityshould be provided in public assistants serveto as teachers’ lacking resources. are schools that adequate Tutors.” “Private highly-educated stipends to providing families hoping to return. A strong emphasis on A strong return. families hoping to English instruction attract included to can also be in resettlement. interested those families most Enhance to Refugee Adults Educated Involve Schools. of Local Capacity or other adult refugees parents refugee to refugee schools to provide ongoing training and and training ongoing provide to schools refugee to and teachers refugee for development professional instructors. qualified more hire to schools allow to governments with the coordination Curricula the Southand Sudan of ensure help will Sudan quality and the relevance of instructional content those for education of Sudanese students’ institutions and promote the mainstreaming the mainstreaming promote and institutions youth. refugee of integration social and Teachers. Refugee for Training opportunities capacity in building promote to should be made available Grants schools. refugee

• • •

CH4: CH4: Education Education

CH4: Education Chapter 5: Access to Quality Affordable Healthcare Access to quality and affordable healthcare is one of the most difficult challenges facing refugees in Cairo. A range of Healthcare: Obstacles to healthcare services, including private and refugee-specific Quality Affordable Care health facilities, does exist to provide medical care for • Low quality public services eligible refugees. However, financial limitations and legal • Expensive private health services restrictions seriously limit refugees’ access to healthcare. • Inconvenient refugee specific health services Refugees interviewed in the course of this research indicated • No dental services in refugee specific clinics that health is one of the most pressing needs, and yet it is • Variable quality of all types of health services also one of the areas where UNHCR-Egypt has considerable • Refugees with closed cases are not eligible for work to do to mainstream healthcare services for refugees in most NGO health services accordance with the goals of its 2009 urban refugees policy.

5.1 Health Insurance CH5: There is a wide array of health services available in Egypt, government providing the rest. This insurance provides Affordable Healthcare Affordable though access and quality of care vary and depend very much only curative treatment, not preventative (Nandakumar on refugees’ legal status and financial resources. In general, et al. 2000a). HIO is currently available only to citizens. the Egyptian government, UNHCR-Egypt, INGOs, religious institutions, private hospitals and clinics or some combination A huge expansion of public insurance took place in of the above can provide medical care for refugees in Cairo. 1992, when insurance benefits, funded through a tax on cigarettes, government contributions, co-pays and private Affordable Healthcare Affordable In 2005, Egypt granted all foreign residents access to donations, were extended to school children. In 1997, the Affordable Healthcare public health services in government primary care clinics Ministry of Health issued a decree that further expanded CH5: CH5: and hospitals at the same cost as uninsured Egyptians. public health insurance to children from birth until school Despite this laudable and landmark expansion of healthcare age (www.hio.gov.eg). This insurance covers preventative access to refugees, recognized refugees tend to prefer and curative primary care as well as eye and dental services. the care provided by NGOs or private clinics. Interviewed As a result, all students in public schools are eligible for refugees deemed these services of better quality than health insurance through the government. Few refugees care provided in government facilities. Only a small attend public schools, and so few benefit from this school- percentage of registered refugees seek treatment at public based insurance. At the same time, community-based facilities, despite the lower cost and relatively easy access. refugee schools often operate health clinics on site and refugee children are able to receive free or inexpensive Refugees registered with UNHCR-Egypt are entitled to care healthcare from these providers (Nandakumar et al. 2000b). from a wide range of healthcare providers. Recognized refugees are eligible for primary care through NGO medical Originally, this governmental insurance scheme was clinics (Refuge Egypt and Caritas, primarily). For tertiary designed to provide benefits for treatment in public care, refugees can seek medical referrals to specialists and facilities only. However, in certain cases, the government private hospitals through Caritas, who also subsidizes a has also partnered with private clinics and hospitals to significant percentage of treatment costs. Unregistered ensure adequate access for school children to health or rejected refugees are largely restricted from receiving services, especially in rural areas where there may not NGO-provided medical care and must pay for their own be a sufficient number of public clinics or hospitals. treatment through public or private clinics and hospitals. The precedent set by the government in providing In 1964, the Egyptian government established the subsidized, public health insurance for a broad population Health Insurance Organization (HIO), which initially to access both public and private healthcare is an important provided government employees and industrial workers starting point for envisioning what a refugee insurance policy with health benefits in public healthcare facilities. This scheme could look like in Egypt. As we will explore in greater coverage was expanded to include pensioners and depth in the recommendations section, a refugee insurance widows. By 1993, there were 5 million beneficiaries, scheme that provides both public and private options is who paid a small percentage of their salaries as a best suited to overcome the myriad of obstacles currently premium (between 1-4%) and small co-pays while the obstructing refugees’ access to health services in Egypt. 5.2 Healthcare Services According to the World Health Organization (WHO), Egypt services to Egyptians and foreigners alike. However, has a broad network of easily accessible healthcare services, both Egyptians and refugees complain about the low including public clinics and hospitals, private healthcare quality of public health services and as a result many facilities, charitable healthcare services provided through locals and refugees choose to utilize parallel systems of mosques and churches, and NGO-provided healthcare for private medical facilities and NGO- or faith-based clinics. refugees. Public clinics and hospitals provide inexpensive

30 CH3: Refugee Livelihoods CH5: Affordable Healthcare An Iraqi Family An Iraqi Those that provide primary their provide through that Those care medical clinics; own and financial referrals provide those that and, assistance; and mental psychosocial provide those that health support. 1. 2. 3. occasions from Caritas, due to health problems health problems due to Caritas, from occasions times at are they However, among family members. form distance as it is a great with Caritas exasperated with refugees, it is often verytheir home, crowded see a doctor times to and long waiting involves complex are There in nature. is very bureaucratic see the doctor multiple trips to rules necessitating of All the clinics. collect as to medicine from as well particularly family. the for troublesome proves this They have received health serviceshealth many on received have They Nearly all refugees who had sought medical care in Egypt in Egypt medical care who had sought Nearly all refugees had who Those degree. some to Caritas with interacted especially dependent were medical conditions complex woman one Iraqi example, For on their financial subsidies. her for costs of cent per 70 pay to Caritas on relied and another Iraqi family treatment, Thalassemia daughter’s son with a their disabled providing for Caritas praised In this instance, much-needed wheelchair and medications. when arrangements funeral for pay also helped to Caritas Several organizations exist to provide referrals (and subsidies) referrals provide to exist organizations Several is the Caritas needs. medical with advanced refugees to and and Africa UNHCR-Egypt though primary center, referral provide sometimes Middle (AMERA) East Refugee Assistance NGO for “gatekeeper” the main Caritas, as well. referrals centers medical different 142 with works healthcare, refugee clinics. including 25 hospitals and 48 private Egypt, throughout 80 up to will usually subsidize Caritas In referrals, addition to very treatments even costly for costs of treatment per cent this is very (Note: and surgeries different like chemotherapy tertiary for pay to at care have refugees where Jordan, from See: without subsidies. nationals, as foreign the same rate reserves Caritas right the 2012). However, Taylor Martin and of need. based on its assessment subsidies or referrals deny to medical and psychosocial support to refugees. There There supportand psychosocial medical refugees. to types basic NGO-based of three are facilities: health primary NGO largest two the are and Caritas Refuge Egypt four has a staff of Refuge Egypt providers. healthcare primaryits main and doctors, twice open is clinic a care patients 150-200 seeing between examinations, for week and children’s in women specializes Refuge Egypt per day. and postpartum anti-viral antenatal care, health, providing adults and for and immunizations treatments, and retro-viral Well Baby these services It its five children. provides through also provides Caritas Cairo. Child clinics throughout Well and 1,000 patients primary serving its clinic, at care approximately and assisting an additional 750 with chronic per month self-sufficient of economically the exception With diseases. for place common the most NGO clinics are these refugees, seek primary to of all nationalities treatment. refugees care when they require medical care (WHO care medical they require when MOH 2009). and types various of provide to exist NGOs Numerous 31 An Iraqi Man An Iraqi An Woman Ethiopian Public Health Services Health Public Private Health Services Private NGO-Based Health Services free healthcare for refugees. No one from the from No one refugees. for healthcare free us about this subject.UN contacted have So we clinics. private from been getting healthcare We didn’t use any refugee health services refugee because use any didn’t We any have didn’t we and because far away, live we offer that about the organizations information the fee is 20LE instead of going to Caritas as Caritas to of going is 20LE instead the fee It is not good early and the suffering. as 6am service—[peoplenothing for often] come and go With the suffering and the money you spend and the money the suffering With NGOs], it is better refugee at get healthcare [to doctor where private the closest go to you that

were the most likely to seek care at refugee-specific at seek care NGOs: the most likely to were clinics medical NGO use refugees Sudanese of cent per 67.7 frequently use these NGOs because they are less expensive less expensive use these NGOs because they are frequently higher provide to facilities but perceived than private health services.public than quality refugees African care Refugee-specific NGOs operate a parallel medical system in Refugee-specific medical system a parallel NGOs operate the services duplicates available ways which in many Cairo, Refugees Egypt. in facilities private and public through which makes self-medication both easy and dangerous. both easy and dangerous. which makes self-medication ailments or when they thought it was too difficult or too or difficult too was it thought they when or ailments In prescription. a subsidized for Caritas to travel to costly without a prescription, available are most medications Egypt, Many refugees self-medicated; they sought advise and they sought self-medicated; refugees Many common especially for pharmacies, private from remedies even higher percentage preferred private services: private 80 per preferred higher percentage even public ones. to hospitals private of Iraqis preferred cent private sector treatment, whether paid for through their own their own through whether paid for sector treatment, private Sixty-two Caritas. per cent from or with subsidies resources visited WHO study had never of Iraqis participating in the an care, advanced it came to When a public health facility. access private clinics for secondary clinics for tertiary and private access with care WHO and Egypt’s In the a study by Caritas. from assistance Ministry of Iraqis preferred of Health (2009), 63 per cent Iraqis, mostly—oftenIraqis, elected taking do so without to a and subsidy. time-consuming a referral for Caritas trip to to able were means financial Refugees adequate without All refugees interviewed for this project perceived private private this project perceived interviewed for refugees All able who were Those qualityclinics as the highest of care. means— own their through healthcare private afford to chose alternative medical centers for treatment. treatment. for medical centers chose alternative write a prescription for something. This leads to constant constant leads to This something. for a prescription write about similar claims many Refugees repeated misdiagnoses.” overwhelmingly and as a consequence, public facilities, refugees alike. One Egyptian told us, “The public health us, told One Egyptian alike. refugees so overcrowded are services, the university, those at like of minutes two each patient give the doctorsthat can barely quicklyand patients their at look Doctors barely time. their Governmental medical facilities are the most numerous in numerous the most facilities are medical Governmental and among Egyptians the least popular they are yet Egypt,

CH5: Affordable Healthcare Affordable

CH5: Affordable Healthcare their son passed away. Caritas also enabled several of that a variety of health services are available to refugees the families we interviewed to get costly chemotherapy and to prevent any one particular NGO from being treatments and operations at private hospitals. overburdened, this has also created a complex and often confusing environment of overlapping services, While the proliferation of NGOs has worked to ensure duplication and sometimes opaque referral protocols. 5.3 Health Issues Egypt has been successful in eliminating many and potatoes) and legumes (lentils and beans). She communicable diseases and in providing sufficient water cooks meat or chicken very rarely: once or twice a month. Refugee Livelihoods and sanitation services to the majority of the population. However, lifestyle-based maladies, including diabetes, All refugees reported spending a significant amount of their CH3: hypertension, smoking-related ailments and psychological resources on food: Iraqis spent an average of 36 per cent disorders are reported to be on the rise by healthcare of their household income on food (by comparison, they providers. Pollution and congestion also adversely spent an average of 20 per cent of household income on affect the residents of Cairo, locals and refugees alike. rent). These food costs evidently constitute a real burden on a sizeable percentage of the Iraqi population in Egypt: Chronic and Tertiary Conditions 37 per cent reported selling household possessions in order to afford food, and 42 per cent reported borrowing money Medical needs vary by refugee population. Many Iraqi in order to pay for food and rent (WHO and MOH 2009). CH5: refugees are middle-aged, come from middle-class urban Malnutrition is even higher among African refugees, who Healthcare Affordable environments and suffer from chronic ailments like dedicate 80 per cent of household income to food. Most hypertension, diabetes and thyroid problems. Many Iraqis African refugees reported borrowing significant sums of also suffer from cancer, and a number of Iraqi children have money to afford their expenditures, which were often several Thalassemia, a genetic disorder, causing the body to make times that of their monthly income (WHO and MOH 2009). an abnormal form of hemoglobin. The disorder results in excessive destruction of red blood cells, which leads to I earn about $130 a month and pay $90 for rent. Affordable Healthcare Affordable anemia. Martin and Taylor (2012) report similar health issues I am able to afford one chicken each month. The Affordable Healthcare experienced by Iraqis in Amman. While African refugees rest of the month we eat rice. Some months I CH5: CH5: also suffer from chronic ailments, they tend to suffer more get from my church a kilo of sugar, a kilo of fava from illnesses resulting from malnutrition as well as from beans, half liter of milk, and a bottle of cooking oil. contagious diseases than do Iraqis. In both populations, a A Sudanese Woman Working as a Maid number of people have debilitating injuries or disabilities that require ongoing medical care: Caritas provides wheelchairs and other forms of assistance to over 250 I eat only twice a day; rice and beans, primarily. I have handicapped refugee patients annually. Only a small number no energy to enjoy recreational activities or sports. of refugees in Egypt reported having HIV/AIDS, though in reality this number may be underreported due to social A Young Somali Man stigmas and legal penalties associated with the condition. Statistics show that most African refugees have had to cut Nutrition meals because of cost: 77 per cent households reported skipping meals because they could not afford food (WHO According to the 2009 UNHCR policy on urban refugees, and MOH 2009). None of the refugees interviewed reported as a general rule, when working in urban areas UNHCR- receiving food assistance and relied instead on their own Egypt should avoid the establishment of separate and resources, borrowed money or shared meals with friends and parallel services for its beneficiaries and should instead relatives. UNHCR-Egypt does provide some food assistance seek to reinforce existing fully authorized service delivery and nutritional supplements to refugees who appear to systems, whether they are public, private or community- have a serious risk of developing malnutrition, and Caritas based. At the same time, UNHCR’s urban policy recognizes also provides some limited food assistance. It is unclear if that special assistance arrangements will be required for these refugees were not aware of these food assistance refugees in situations where they are excluded from national programs or if they were not eligible for these services. welfare programs, such as the provision of subsidized food. UNHCR’s Global Strategy 2010-2011 has also addressed food Little research has been done to determine the precise impact security and nutrition as one of the priority response areas of poor nutrition on refugee children and families. However, whereby refugees are to benefit from sufficient quantity stakeholders indicated that malnutrition is evident among and quality of food, adequate to their specific needs, refugee children and that more research and interventions including their age and physical condition (UNHCR 2011d). are required to mitigate the consequences of poor diets. Furthermore, stakeholders also report high instances of Both refugees and Egyptians complained about raising vitamin D deficiencies among refugee children because prices of foodstuffs and suffered, to varying degrees, from families often keep their children indoors in order to ensure poor nutrition. One Egyptian woman indicated that the their safety, because of limited educational opportunities in increase in food prices is not commensurate with most Egypt and because African refugee women are more likely to people’s income. She shared with the interviewers that she be employed outside of the home and lack adequate childcare. had to make changes in her family’s diet to accommodate the growing cost of groceries. The meals she serves her Reproductive Health family consist mainly of vegetables (tomatoes, cucumbers

32 Antenatal care appears to be good in Egypt, where public the majority of Sudanese refugees he encountered were rape and private clinics as well as refugee-specific NGOs provide victims. A medical doctor told us that there are also a number

prenatal and post-partum care for expecting mothers of Iraqi and African refugee women who became victims of CH3: and young children. More than 70 per cent of both Iraqi sexual abuse or domestic violence since arriving in Egypt.

and African pregnant refugees received pre-natal care in Livelihoods Refugee Egypt. Postnatal care was less adequate, however, with However, according to the Center’s resident psychiatrist, 40 per cent of Iraqi refugee women and fewer than 20 the majority of refugees seeking services from El Nadim per cent of African refugee women receiving postnatal Center were looking for medical affidavits testifying care within a week of delivery (WHO and MOH 2009). that they were torture survivors in the hope that such affidavits will ensure resettlement in the U.S., Canada or Following the typical pattern, Iraqi women most often Australia. As soon as they receive the coveted affidavits, sought antenatal care from private facilities, while many refugees do not return to the Center. The staff is African women most often sought care from NGOs convinced that refugees from war-torn countries would (WHO and MOH 2009). Among the refugee-specific benefit from psychiatric and psychosocial services therefore NGOs, Refuge Egypt has established itself as the primary they try to entice refugees to come for counseling at provider for reproductive health, including prenatal least 3-4 times before the doctor issues the affidavit. care, TB shots and HIV-related tests and treatment. Social isolation is a common problem reported by many Psycho-Social Health refugees in Cairo. Family and community support can also

CH5: act as protective factors for some refugee populations. CH5: Although psychosocial programs have been a key In Cairo, psychosocial support and community cohesion Affordable Healthcare Affordable component of international policy, there is much confusion varies between refugee populations. Generally speaking, Healthcare Affordable over their meaning among aid agencies and the concept Sudanese refugees tend to live in the same neighborhoods is under-theorized in academia (Pupovac 2001). The term and have developed a number of schools and other “psychosocial” is often: “used to indicate commitment to non- community-based institutions. Iraqis, in contrast, live in medical approaches and distance from the field of mental neighborhoods scattered throughout Cairo and have not health, which is seen as too controlled by physicians and too developed many community-based associations, in part

Affordable Healthcare closely associated with the ills of an overly biopsychiatric due to government prohibitions on Iraqi community- approach” (van Ommeren et al. 2005: 71). Ager points out based organizations. On the other hand, Ethiopians and CH5: that activities that come under this label range from trauma Somalis have experienced greater social dislocation than counseling to peace education programs, life skills, self- have the Iraqis and (to a lesser extent) Sudanese, because esteem and empowerment building activities, and sports few refugees from East Africa speak Arabic, the national and recreational pursuits, to name but a few elements. The language of Egypt. Despite some differences in community aims of these programs are to prevent trauma and stressors support, almost all refugees reported high levels of social that negatively affect mental health to whatever degree isolation. Many reported spending all day at home with few possible and to strengthen the capacity of refugees to cope outside interactions. Iraqis in particular noted that they have with traumas and stressors when prevention fails (Ager 1993). few friendships with non-relatives, in part due to the lack of Refugees in need of mental healthcare, psychosocial communal cohesion noted above. Lack of entertainment support or services for victims of sexual and gender-based and inability to travel are cited as two important barriers violence (SGBV) are most likely to seek such care through to socializing, along with anxiety about leaving home or NGOS providing refugee-specific care. AMERA provides allowing one’s children to leave the home unsupervised. psychosocial support and counseling, especially to victims A number of Iraqi and African refugees indicated that they of sexual or domestic abuse. In some instances, they are participated in psychosocial programs, with programs also able to provide referrals or subsidies, especially to at St. Andrew’s being the most popular. In general, Iraqis unregistered refugees. The Association for the Development were more open to mental health programs than African and Enhancement of Women (ADEW) operates a shelter refugees. Urban and well-educated Iraqis did not attach as for women; a few of the refugees interviewed were aware much stigma to mental health issues, as did refugees hailing of its existence and knew women who had used the from other cultures and backgrounds. The size of refugee shelter. The Cairo Family Planning Association provides communities may also make it more difficult for members of reproductive healthcare primarily to Egyptians, but certain small refugee communities (for example Ethiopians) has provided services to refugee populations, as well. to seek services discretely. Fear of stigma and harassment is For specialized mental healthcare, most refugees used El a persistent and significant barrier that keeps many refugees Nadim Center for the Rehabilitation of Torture Victims. This from seeking help. Some refugees feared that other organization works specifically with survivors of torture refugees or Egyptians would mock or harass them if they and violence, both Egyptians and refugees. Despite stigmas were seen seeking mental healthcare. For this reason, it may attached to mental health services, several Iraqi and Ethiopian be beneficial to integrate mental health services into other refugees indicated in interviews that they were undergoing programs, including primary healthcare clinics and schools. counseling and receiving medication from the El Nadim My son used to get top grades in school in Iraq. Center for depression, anxiety and post-traumatic stress Here he is so discouraged that he has begun disorder (PTSD). Though it is difficult to assess the prevalence failing his classes. He is withdrawn and depressed. of SGBV, PTSD and other forms of trauma among the refugee I too am depressed and discouraged. There are community, both stakeholders and refugees alluded to the no opportunities in Egypt. I sit at home all day. possibility that such experiences may be common among certain refugee populations. One stakeholder indicated that An Iraqi Father

32 33 As a result of difficult past or present circumstances, several out mental health specialists in the private healthcare refugees reported experiencing depression while in Cairo. sector for counseling and, more often, for prescriptions Some Iraqis reported that the depression resulting from for psychotropic drugs. It seems that BPRM and UNHCR these losses was severe enough to cause suicidal ideations; should assess the Iraqis’ reliance, perhaps overreliance, others mentioned the need to resort to psychotropic drugs, on psychotropic drugs and initiate programs aimed at including anti-depressants and sedatives. Some indicated decreasing social isolation and preventing depression that these medicines were very costly, and that they had to without drugs when participation in recreational choose between taking their medications and spending their activities or artistic events might have a similar effect. money on food, tuition and rent. According to healthcare providers interviewed for this study, middle-aged male Some of the interviewed refugees sought help from Refugee Livelihoods Iraqi refugees are at the greatest risk for prescription drug outpatient and in-patient facilities, including the largest abuse. In contrast, Sudanese and East African refugees are mental health facility in Cairo: the Abbasyia in-patient CH3: more likely to suffer from addictions to alcohol or, more hospital. Despite negative public associations with Abbasiya rarely, hashish or heroin. El Nadim Center has a regular for its former asylum-style care, 10 refugees sought Narcotics Anonymous meeting, but does not have an treatment there in 2010. They were treated for anxiety, PTSD, Alcoholics Anonymous meeting. Given the easy access to attention deficit and hyperactivity disorder, and depression. prescription medications, including anti-depressants, it In 2010, a new Mental Health Act reformed the behooves service providers to educate refugees about the Abbasyia asylum. Under this new law, mental

dangers of self-medication and mixing of psychotropic health patients gained new rights relating to CH5: drugs with other medications. Researchers indicate that an their treatment and discharge. However, after appreciation of clinically important interactions is becoming the Revolution in 2011, parts of the act were Healthcare Affordable increasingly necessary with the rising use of combinations repealed, reducing patients’ freedoms. Some of of drugs in the management of chronic medical conditions the law’s provisions for refugees were weakened. (Chadwick et al. 2008). Many of the Iraqi refugees in Cairo are middle-aged, and as they grow older and are more Refugee youths can seek mental healthcare likely to take several drugs concurrently, they are at greater in three different governmental hospitals: at the juvenile mental health clinics in Abbasiya Affordable Healthcare Affordable risk of an adverse drug interaction than younger people. Affordable Healthcare hospital, Helwan hospital and Khanka hospital.

Refugees and service providers indicated that psychosocial CH5: CH5: problems often exacerbated existing physical and Caritas has also developed and improved its employment problems. For instance, one Iraqi suffered from referral system for refugee patients to receive a high degree of anxiety that has made it difficult for him to mental healthcare at Abbasiyya hospital. seek medical assistance due to the overwhelming conditions One major problem that remains is access: of Cairo’s traffic, crowded waiting rooms, and long wait times the few public mental health clinics that exist before appointments. For those who do have jobs, mental are often located far away from refugees health problems can make it difficult to maintain employment. One Ethiopian woman has been hired as a housekeeper or Mental health professionals from the American University nanny in many different homes, but she is frequently fired in Cairo and PSTIC have tried to remedy this problem because of severe forgetfulness brought on by emotional by primary care providers to recognize signs of mental turmoil resulting from her detention and torture in Ethiopia. health disorders and refer patients to appropriate care. Work remains to be done to ensure better Refugees seeking mental healthcare can turn to access to refugees in need of mental health services. NGOs, private clinics or public institutions. Caritas provides psychological screenings at their primary The Psycho-Social Training Institute of Cairo (PSTIC) and care facility and refers refugees, when necessary, to UNHCR-Egypt have recently formed a partnership to address the El Nadim Center and other psychosocial programs. psychosocial issues facing refugees residing in Cairo. El Nadim Center was first established in 1993 to Social Training Institute in Cairo (PSTIC) began in provide rehabilitation and advocacy for victims 2009 in order to providep psychosocial and mental of torture or SGBV. While El Nadim Center began health services to refugees in Egypt. To this end, its work focusing on Egyptian victims of torture, it PSTIC provides trainings and workshops for refugees expanded its scope to work with female victims of to develop psychosocial and mental health support violence and with Sudanese and Iraqi refugees. In within their own communities. The goal of PSTIC is addition to providing counseling and medical care at to have these trained refugee psychosocial workers its offices, staff at El Nadim also run training programs to become an “important source of support to their that equip volunteers to provide counseling communities” while also serving as a “bridge for services and advocacy at a grassroots level. psychosocial assessment, support, crisis response and advocacy between refugee communities, For more information, see: https://alNadim.org/en/ NGOS, and Goverernment and UN organizations” node/23. (Adapted from PSTIC website http://www.aucegypt. The El Nadim Center is also one of the few NGOs that have edu/GAPP/cmrs/psychosocial/Pages/(PSTIC).aspx). doctors qualified to write prescriptions for psychotropic The partnership between PSTIC and UNHCR- drugs. As already mentioned, Iraqi refugees rely heavily on Egypt seems to be a promising initiative although anti-depressants to alleviate their suffering. Some Iraqis without a rigorous impact evaluation it is difficult interviewed for this project indicated that they had sought to assess the efficacy of psychosocial programs.

34 CH3: Refugee Livelihoods CH5: Affordable Healthcare Distance Crowding and Long Waits Long and Crowding expectations that healthcare should be free and convenient, convenient, and free be should expectationshealthcare that discomfort racial and class to due and Iraq, in many for it was as refugees. with African areas in crowded waiting from efficiency improved for be room appears to there the same, All appointments. procuring for procedures dignified more and courtyard is a small there example, for office, the Caritas At a a staff person through speak to to wait refugees where Refugees must nearly one floor above. is located that window necessary pass any paperwork to strain the staff through to pushed the Egyptian Ministry the Egyptian pushed UNHCR, Caritas of Health, into refugees mainstreaming begin NGOs to and other This extent than before. a greater public health facilities to depth below. in greater will be explored development complained all interviewed refugees exception, Without which has Caritas, to travel to they have about the distance to in travel refugees must to which office only one central healthcare. advanced and subsidies for get referrals to order have who those with along verythe elderly, and ill For and hardship, a real constitutes the distance small children, times been have there that interviewees indicated many (or paid go without medical care chosen to when they have to than travel rather care) to seek private sums significant Refugees living on the outskirts office. Caritas the central Caritas. reach hours to two for travel to of the city have at about long lines and crowding complained refugees All been the most refugee-specific have Iraqis health clinics. In that Iraqis interviews, indicated in this regard. vocal their both from stemmed their discomfort with crowds despite horrific life experiences (Mollica et al. 2002: 158). The 158). 2002: (Mollicaexperiences et al. horrificdespite life policyrefugee create to makers for emerges recommendation support that practices work,programs religious indigenous and culture-based refugees. among altruistic behavior impactthe on had a negative has also revolution The speaking, Broadly being of refugees. well psychological of instability an environment has created the revolution less reported feeling refugees many where and anxiety, or violence potential to vulnerable and more secure as social isolation also has increased revolution The abuse. their apartments leave and venture to fear refugees many well- their mental inevitably worsens out; this situation also Refugees have bonds. communal being and weakens access to at times difficult reported it has been more that during periods psycho-socialand health programs mental not attend could boy one refugee of demonstrations: instance, for Andrew’s, a psycho-social St. at meeting the revolution the same time, At protests. because of nearby promising, but need further need but 2001; (UNHCR assessment promising, the extraordinary suggests Research 2001). capacityUNESCO illness against mental themselves protect to of refugees , 35 Access to Healthcare to Access A Somali Man 5.5 The Effects of the Revolution Effects Revolution of the The 5.4 on Refugees’ Health and Well Being Well and Health on Refugees’ Cost Principles and Guidance for Referral for Referral and Guidance Principles the fees [for medical treatment] and I do not medical treatment] [for the fees the fees to contribute money to the have eat. enough to even not have I do required. Caritas says always that I should pay half of I should pay that always says Caritas

secondary and tertiary for especially needs, healthcare ongoing care. and costly require diseases that chronic Egypt noted its in 2009 noted Egypt of Concern and other Persons for Refugees Healthcare refugees’ all of to meet funds sufficient never are there UNHCR-Egypt and its implementing partners and its implementing UNHCR-Egypt also secondary adequate tertiaryand provide to struggle As UNHCR- refugee patients. to prices affordable at care Egypt with some resources. Data on the frequency Data of visits with some resources. Egypt the Ministrymedical facilities collected by to of Health hypothesis this WHO confirms (WHO and MOH 2009). and Costly treatments for serious illness or injury for can severely treatments Costly in those families who arrived of even savings deplete to seek even heavily subsidized medical care through Caritas. Caritas. through care medical subsidized heavily even seek to a significant number of destitute refugees. One Somali refugees. number of destitute a significant interviewed had a number of serious health issues, refugee unable was but injuries infections, and traumatic including Similarly to in Amman (Martin and Taylor 2012), refugees 2012), refugees Taylor (Martin Amman in Similarly to and of medical care. about the cost complained in Cairo for hardship a real presented fees nominal medical Even self-sufficient refugees (Iraqis, primarily) have begun to turn to begun have primarily) refugees (Iraqis, self-sufficient medical and financial services. charities NGOs for and to reduced their caloric intake and dramatically changed dramatically and calorictheir intake reduced budget in the aftermath of the revolution their food has reportedCaritas and an UNHCR-Egypt (IOM 2011). as previously registration number of refugee increasing following the revolution has made it more difficult for difficult has made it more the revolution following nutrition. proper maintain to or medicine afford to refugees of all refugees than 80 per cent more that IOM found own clinics or through partnerships clinics or through own with hospitals and resumed normal since have offices These clinics). private downturn the economic significantly, More operations. seek medical care at their usual clinics due to insecurityto clinics due their usual at in care seek medical great to went closings (though NGOs or office the streets their through emergency medical care provide to lengths The Egyptian revolution appears to have worsened the worsened have to appears revolution Egyptian The In the initial board. the across refugees for health situation unable to were refugees many of the revolution, days results of the UN experience with emergency of the UN experience and peace results capital seem social improving aimed at initiatives education 2009). Globally, the evidence base for specific psychosocial specific psychosocial base for the evidence 2009). Globally, and Mimica Agger 2002; interventions is small (Mollica et al. initial hand, On the other in Egypt. nonexistent 1996) and participating in various psychosocial programs, the benefits the benefits participatingprograms, psychosocial in various aid international assumed by are programs of psychosocial (Gozdziak research backed up by than rather organizations, While refugees reported positive experiences from from experiences reportedpositive refugees While

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CH5: Affordable Healthcare this window. One Somali refugee explained: “Psychologically, get financial help from Caritas for my treatment. at Caritas, refugees are not respected. They go and talk to After the second doctor I went to an NGO called someone higher than them. Sometimes they are thrown AMERA (Africa and Middle East Refugee Assistance) their cards. There is no privacy because they are asked and from there I was referred to a gynecology what they want through the window in front of everybody.” specialist and he has prescribed an injection called Zoladex, six injections in total to be taken over a Opaque System period of six months, one injection every month. The overlapping and sometimes duplicative services offered An Ethiopian Woman AMERA, by various NGOs, in addition to the bureaucratic protocol paying for her treatment through grants required to receive referrals and subsides for advanced care, creates a complex and sometimes confusing system Quality of available health services. As our colleagues also found in Jordan, refugees often experience a lot of “to and froing” by One significant barrier to healthcare for all refugees, but for different refugee-specific health organizations due to the Iraqis in particular, is a perception of quality of public and limited scope of services provided by any one organization refugee healthcare services in Egypt. Private healthcare is and the bureaucratic necessity of obtaining referrals for sometimes criticized, but it is widely regarded as the best certain services (Martin and Taylor 2012). Combined with healthcare available in Egypt. Furthermore, a number of long wait times at many clinics and refugee health offices, refugees consider private healthcare the only adequate many refugees of all different origins expressed exasperation healthcare in Egypt, and some will forego treatment CH5: at the complexity of the system. Frustration with bureaucratic altogether if they cannot afford to access needed services in Affordable Healthcare Affordable hassle pushes even some financially destitute refugees a private setting. Although some refugees, especially among to seek care at private clinics instead. One Somali refugee the Iraqi population, have adequate household savings to told us that with the “suffering and the money” she would afford private healthcare, nearly all refugees are banned from spend to make repeated trips to refugee health offices, working formally, and thus their financial situation worsens she found that it was “better…to go to the closest private every day. As a result, a decreasing number of refugees doctor where the fee is 20LE instead of going to Caritas as are able to afford what they perceive to be adequate and Affordable Healthcare early as 6 am and suffering.” The sometimes confusing health quality care. Though it may not be sustainable to provide Affordable Healthcare environment is even more challenging for unregistered reimbursements or subsidies for private healthcare for CH5: CH5: refugees, who have limited resources available for healthcare. refugees in all instances, quality of care must be recognized as a formidable obstacle for refugees seeking to maintain At one time I got very sick and I was admitted to Magdi their health in dignity. Likewise, this is a significant obstacle hospital in Dokki and I had to receive blood transfusion for many Egyptians, who cannot afford private care but do and the doctors said that I have a fibroid in my uterus not regard public health services as suitable or adequate. We and that I needed to have a surgery to remove it. suggest below that offering subsidized insurance benefits to Because I did not have a blue card since I was not refugees may be the best way to overcome this particular recognized as a refugee by the UNHCR-Egypt, I couldn’t barrier and improve the accessibility of quality healthcare. 5.6 Efforts to Mainstream Refugee Healthcare UNHCR-Egypt, Caritas, Refuge Egypt and other NGOs continue working out of hospitals, such as the emergency are aware of the inefficiencies of the current refugee room set up for refugees at Sanabel Hospital. According to healthcare delivery system and resulting refugees’ stakeholders, this was a positive development for Caritas in complaints. Recently, there have been two laudable helping to realize the benefits of partnering with Egyptian developments aimed at improving healthcare for refugees hospitals to alleviate wait times and bureaucratic hassle. in Egypt. The first has been an effort to decentralize the refugee healthcare system and second has been A second initiative would transition refugees entirely into to mainstream refugees into public health institutions. the Egyptian public healthcare system with NGOs assisting only in dire and exceptional cases. In some ways, the door The most obvious inefficiency in the current very complex is already open to mainstreaming refugees: all foreigners refugee healthcare system is that the central Caritas office have the right to access public healthcare facilities for in Garden City has become a bottleneck through which primary and preventative care on the same basis as uninsured most refugees need to pass in order to receive primary nationals. The Ministry of Heath recognizes the public medical care, referrals to specialists and healthcare health benefit of providing immunizations to all refugee subsidies. The long distances and wait times associated children and treating diseases for the entire population. with this bottleneck have been detailed above. Starting in 2010, Caritas began plans to decentralize its services, Structural barriers exist that keep refugees from utilizing positioning Caritas-affiliated doctors in a variety of different public services more fully. First, there is no standard system hospitals and clinic settings, where refugees can receive for providing translation and interpretation for non-Arabic referrals and diagnostic tests without traveling to Garden speaking populations, though the Center for Migration and City. These doctors are situated in neighborhoods with Refugee Studies at the American University in Cairo has a high concentrations of refugee populations. The Egyptian program to provide translation and interpretation services revolution helped to expedite this transition from a for refugees in refugee medical clinics, which should be highly centralized system: during the initial phase of the expanded. Second, precisely because a parallel system revolution, Caritas was not able to operate its Garden City of refugee healthcare exists (and one that is perceived offices. However, Caritas-affiliated doctors were able to to be of better quality than public clinics), refugees have 36 CH5: Affordable Healthcare primary or mistaken arrests. or refoulement refoulement UNHCR-Egypt should negotiate with the should negotiate UNHCR-Egypt As indicated above, all foreigners have the have all foreigners above, indicated As help restore ties between the government and the the government ties between help restore the government’s demonstrating by Iraqi refugees they are of where regardless its population, for concerns encourage might In turn, typethis located. program of the legitimacy demonstrating of by repatriation of the refugees. in the eyes the Iraqi government Healthcare the Egyptian Refugees Into Mainstreaming System. for facilities public healthcare access right to degree of responsibility sharing of responsibility UNHCR- between degree a corollary As of Egypt. and the Government Egypt agencies development initiative, this insurance to the capacity expand the Egyptian of to can also help qualitythe care its of improve and system healthcare refugees. as well as populations of local benefit the for eliminate to scheme is the best way Such an insurance services, services, bottlenecking parallel overlapping of service and the cost limited at providers of refugees Furthermore, system. healthcare refugee the current the increase help would cards health insurance further in Egypt, of refugees protecting documentation of threat the from them Healthcare Tertiary Secondary for and Fund Special Iraqis. for establish a special fund for of Iraq to Government secondary and tertiary in order Iraqi refugees for care some of the financial impactrefugees on reduce to particularly system, mainstream the and effortsif to healthcare of the Egyptian the utilization increase Extending this support succeed. Iraqi to system Iraq to return to unable or unwilling who are refugees financial Iraq’s be within time would the present at capacity and an extension it has of the responsibility also Such a fund may its citizens. taken on for already and accessibility of care, enhance the dignity of refugees the dignity refugees of enhance of care, and accessibility medical them with a variety for of choices providing by of and mainstreaming services, the integration enhance a greater and promote intuitions Egyptian into refugees • • to improve the referral system of refugees’ secondary and of refugees’ system the referral improve to tertiary sectors. private in the public and needs healthcare and its UNHCR-Egypt guiding principlesfor call These establish to structures, parallel creating partners avoid to provide to professionals, of health committee a referral the referral about clear communication with refugees a memorandum sign and to limitations and its process implementing UNHCR-Egypt, between of understanding Itpartners institutions. is unclear healthcare and national has been able to Egypt UNHCR-Egypt extent what to If fully these recommendations. implement to take steps recommendations these however, Egypt, in implemented of refugees mainstreaming greater facilitate to help would health needs. complex institutions for health Egyptian into (Cairo Standard Operating Procedure: UNHCR 2010b). UNHCR Procedure: Operating Standard (Cairo principles guiding of list a out laid also has UNHCR-Egypt 37 phase in, phase Insurance is not Insurance Recommendations 5.7 from parallel healthcare services healthcare parallel and to from through the subsidized insurance scheme. Using Using scheme. insurance the subsidized through efficiencythe improve greatly will insurance subsidized would dramatically change their role from one of the from change their role dramatically would provide to primary healthcare of refugee providers care receive unable to services those who are only for centers and hospitals. Clinics through Caritas and Caritas Clinics through and hospitals. centers those health for exist to continue would Refuge Egypt but schemes, under insurance not covered conditions with greater household income, some might electmight some to income, household with greater secondary primary, for access policya grants for that pay or tertiary healthcare public or private through care insurance for primary care at public healthcare facilities, primary facilities, for public healthcare at insurance care of BPRM, the Government UNHCR-Egypt, by subsidized refugees For donors and other funders. private Egypt, to provide a refugee-specific policy. This policy would a refugee-specific provide policy. to could refugees that of care levels different provide instance, For income. household their on based in enroll health free all refugees provide might UNHCR-Egypt providers and potentially the Government of Iraq to of Iraq to the Government and potentially providers and viabilityassess the costs of working with Egypt’s insurers and/or private public health insurance national the desired healthcare services and abilities to pay for services for healthcare pay to abilities and desired the in partnershipservices. should then work UNHCR-Egypt Ministrywith the Egyptian of Health, INGO healthcare Note on Health Insurance Schemes for Refugees and Schemes on Health Insurance for Note A viable UNHCR-Egypt. to concern of Other Persons a detailed surveyrequire of first pilot scheme would public (or private) healthcare clinics and hospitals healthcare public (or private) they the care can afford refugees while ensuring that which exist, insurance models of refugee Several need. 2012 Guidance in its March reviewed UNHCR-Egypt asylum indicate that refugees in Egypt would likely would in Egypt refugees that asylum indicate voluntary of a insurance the provision benefit from into refugees mainstream simultaneously to program system: only approximately 50 per cent of all Egyptians all Egyptians of 50 per cent only approximately system: policies. insurance private or public by covered are of health practices in other countries Innovative Subsidized Healthcare Insurance. Insurance. Healthcare Subsidized healthcare of the Egyptian feature a widespread

• phase out phase advocated” as has been public healthcare in mainstream urban refugees can be mainstreamed in standard and and in standard be mainstreamed can urbanrefugees then serviceshealth nationals, peer quality Public for as to progressively efforts be addressed will all coordination NGOs to provide for the costs of treatment—leads to the to of treatment—leads the costs for provide NGOs to in healthcare of refugee system of a parallel persistence the same, All one. verya situation the current similar to where that “ensure to committed remains UNHCR-Egypt services. For refugees to become fully mainstreamed, the mainstreamed, fully become to refugees services. For least at for provide need to would Egypt of Government refugee alternative—for The of treatment. costs some of the significantly, refugees only have access to primary access and only have refugees significantly, is not free, care Tertiary public health services. preventative these for pay to alike need and Egyptians and refugees few incentives to use public healthcare. Third, and more more and Third, healthcare. use public to incentives few

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CH5: Affordable Healthcare and preventative care on the same basis as uninsured Strategies. Refugees, who are coping nationals. UNHCR-Egypt should assess the feasibility of sufficiently well with their circumstances, closing the existing parallel system of refugee-specific should be provided with psychosocial services healthcare services and divert resources supporting based on culturally appropriate indigenous these services to offset the costs borne by the Egyptian strategies to maintain their resiliency and government in providing health services to refugees. mitigate the adverse effects of current stressors. UNHCR-Egypt should also evaluate mainstreaming strategies implemented by the Government of Jordan • Provide In-Patient Mental Health Services for to assess their applicability to the Egyptian context. Severely Mentally Ill Refugees. For severely mentally ill refugees, UNHCR-Egypt should discuss • Decentralizing Refugee Healthcare. UNHCR-Egypt the possibilities of providing in-patient mental could continue to decentralize refugee healthcare healthcare through Abbasyia in Cairo, provided while maintaining Caritas as an important subsidizer of that UNHCR-Egypt can guarantee that refugees secondary and tertiary healthcare. Fully implementing would maintain the same rights and freedoms to this plan will require negotiations with doctors and refuse treatment or voluntarily leave the facility hospitals, each of which may insist on a different rate of pay as Egyptian patients and that UNHCR-Egypt for referrals, lab use, and so forth. Furthermore, UNHCR- could continue to provide a protection space Egypt will need to develop a system by which Caritas for these in-patient treatments. If no suitable can approve referrals and subsidies without requiring agreement can be made, UNHCR-Egypt and refugees to come to their central offices in Garden City. other international organizations should expand CH5:

upon the current protocol for emergency mental Healthcare Affordable • Rethinking Refugee Mental Health. UNHCR-Egypt or health in the Cairo Health Standard Operating BPRM should commission a rigorous epidemiological Procedures so that El Nadim Center, St. Andrew’s, study to assess prevalence of mental health problems Refuge Egypt and/or other providers of mental among refugees in Cairo differentiating between those and psychosocial care can initiate referrals for presenting with severe mental health problems and those emergency mental healthcare with UNHCR-Egypt. that can benefit from preventive mental health services. References

Affordable Healthcare Services and strategies should be based on empirical • Provide Ongoing Professional Development research findings not on casual assessments of the level and Training to healthcare personnel at CH5: of trauma experienced by different refugees by service Caritas and Refuge Egypt to recognize signs providers and refugee advocates, particularly those of severe mental disorders and distress promoting the trauma model and narrative. The trauma in order to provide appropriate referrals. narrative has often marginalized alternative discourses based on survival, strength and coping in the face of • Build Capacity Among Refugee Community- adversity and minimized the role of individual agency Based Organizations and Networks to Provide or meaning, which can have particular significance for Indigenous Psychosocial Assistance to Refugees refugees fleeing armed conflict and civil wars (Tribe that Need Support. Currently AMERA and St. 1998, 2004; Bracken and Petty 1999; Ahearn 2000). Andrew’s provide psychosocial support programs with BPRM funding. These organizations • Integrate Mental Health Screenings and Referrals have trained staff members and semi-trained into Primary Care. This is especially feasible in volunteers. Periodic trainings and professional NGO-based healthcare, such as in Caritas and improvement workshops done through Refuge Egypt. This strategy will go a long way Egyptian medical universities and international towards minimizing the stigma of seeking mental organizations can help expand the capacity of health services or psychological counseling. these organizations. Funding should continue and should also be made available on a pilot • Focus on Resiliency and Indigenous Coping basis to other community-based organizations.

38 References local integration” be implemented. We have discussed have We be implemented. local integration” small strategies—both reportsuch the throughout many by livelihoods refugees’ and large—aimed improving at Our legally in Egypt. work to them the right according the labor market would to access that suggests research self- economically become to not only enable refugees Another wellbeing. their would also improve but sufficient, is the possibility important integration refugee factor for unlike other refugees Iraqis, of community organization. associations. their own form to allowed not are in Egypt, self- form to allowed legally are that Refugeegroups much capacity get organized. to not have do help groups said Refugees recently for HighThe Commissioner that there for new beginning is“a an opportunity today for (Kagan cannot 2011:1). Egypt in Egypt” protection refugee (Sadek,country 2010); the must host” “indifferent an remain This there. who reside engaged with refugees more become citizens.Egyptian and refugees both benefit would engagement 39 Conclusions , UNHCR non-refoulement Chapter 6: Chapter

We suggest that in the interim, strategies aimed at “temporary aimed at strategies in the interim, suggest that We repatriate, and Egypt would grant permanent residency to grant would and Egypt repatriate, (Kagan or be resettled 2011). who cannot repatriate refugees would continue to support to continue social serviceswould refugees, for when possible, be promoted would voluntary repatriation who cannot refugees be used for would and resettlement the stated purpose of implementing Egypt’s obligations obligations purpose Egypt’s implementing of the stated based on the principle of shared law, under international recommitting Government with Egyptian responsibility principle the of to themselves He suggests, and our research team concurs, that the best the that concurs, team research our and suggests, He to of Egypt Government ask the UNHCR to is for forward way the 1954 Memorandum of Understanding with renegotiate their situation, most recently by Michael by Kagan recently most (2011) who their situation, of rights both the addresses that a bold strategy calls for as a country. Egypt of and the interests under law refugees Refugees in Egypt have endured many years of protection protection of years many endured have Refugees in Egypt forth been put remedy to have recommendations Many crisis. References

CH5: Affordable Healthcare References 455. 2008 Chadwick etal. 2012 (CAPMAS) Central for Agency Public andStatistics Mobilization 2010 Buscher, Dale, andLauren Heller 2004 Briant, Natalie, andAndrew Kennedy 1999 Bracken, Patrick, andCelia Petty 1997 Bracken, Patrick, JoneE. GillerandDerek Summerfield Sage. 2007 Bazeley, Patricia 2006 Fatah,Azzam, ed. 2008 Mulki Al-Sharmani, 2000 FredereicAhearn, L.,Jr. (ed.) 1996 Agger, Inger, Mimica andJordanka Review. 1993 Ager, Alastair British Journal ofClinicalBritish Journal Psychology Questionnaire (SMQ).”Southampton Mindfulness and Reliability and Images: Validity ofthe to Unpleasant Mindfully “Responding Thoughts of Egypt. February. Cairo: Government oftheArab Republic “Unemployment Tate intheFourth Quarter.” 18 34(Feb): 20-21. Malaysia andEgypt.” “Desperate Lives: Refugee Urban Women in ofRefugeeJournal Studies “Priorities Setting.” inanUrban ofAfrican Refugees Association Books. theTraumaRethinking ofWar. of Refugee Studies Wartime Violence andRefugees.” Health Mental “Rethinking Work of withSurvivors withNVivo. Analysis Qualitative Data University American ofCairo.Department, Cairo: Forced Studies Migration andRefugee “A Tragedy of Failures andFalse Expectations.” , 18-20April. and Research Methodology, KoçUniversity, in theEuropean Space: Theory, Politics conference Irregular Transit Migration “Transit or Transnational?” Paper presented at the Berghahn Books. Qualitative andQuantitative Research. Psychosocial Wellness ofRefugees: Issuesin European Office. Community Humanitarian Herzegovina Evaluation. andCroatia: An Psycho-social Assistance to Victims ofWar inBosnia- Culture andMedicine. Mental HealthIssuesinRefugee Populations: A Boston: Harvard CenterBoston: Harvard for theStudy of 10(4): 431-442. Forced Migration Review 17(4):437-459. London: Free Journal 47(4): 451- References New York: New York: Brussels:

40 Perrin Di Bartolomeo, Anna, Tamirace Fakhoury and Delphine University. 2012 Davis, Rochelle 2004 Crisp, Jeff 2011 Chatelard, Géraldine 1991 andGordon R.ConwayChambers, Robert, Matter. 2008 2006 2005 Katarzyna Grabska, 2008 Fielden, Alexandra 2005 El-Abed, Oroub FIDH. 2007 (International Federation for (FIDH) HumanRights The Egyptian Initiative for Personal (EIPR)andFIDH Rights 2010

Sustainable Rural Livelihoods: Practical Concepts for Contemporary Arab Studies, Georgetown Study ofInternational Migration andCenter Abbie Taylor. Washington, D.C.: for Institute the inAmman, Jordan.” Refugees “Urban With Global Commission onInternational Migration. Working Paper No. 102.Geneva: AConceptualRefugees: Analysis.” andHistorical Local Integration andLocal“The of Settlement Recherche Stratégique. D.C.: andFondation EastInstitute Middle pourla to Durable Solutions.”Intervention Washington, andIDPs: Refugees “Iraqi From Humanitarian Development Studies, University ofSussex. for the21stCentury. L. Mehta (eds.)L. Mehta Well-Being inEgypt.” ofRefugees and Grabska K. In “Brothers orPoor Cousins? Rights, Policies, andthe Refugee Studies inCairo.” Refugees Urban South: “Marginalization Spaces inUrban oftheGlobal UniversityAmerican inCairo. Center for Studies, Migration andRefugee the Closed Files inEgypt.” Working Paper No. 6.Cairo: Livelihood Strategies with ofSudaneseRefugees “Living ontheMargins: The Analysis ofthe Refugee Research: Areas.”Urban Research Paper No. 161. “Ignored Displaced Persons: thePlight ofIDPs in Are Left for Them?” “Palestinian ofEgypt: Refugees What ExitOptions oftheirFamilies.and Members Cairo: EIPRand the Protection ofAll Migrant oftheRights Workers to theUNCommissionAlternative on Report Workers of andMembers Their Families.” NGO “Egypt: Protection ofAll Migrant of theRights Applied Research onInternational Migration. “Migration Profile: Egypt.” Florence: for Consortium London: Palgrave Macmillan. Forced Displacement: Why Rights 19(3): 23. Brighton: of Institute Refuge 22(2):15-30. of Journal

New Issuesin References

References CH5: Affordable Healthcare Gozdziak, Elzbieta M. University. 2002 “Spiritual Emergency Room: The Role of Spirituality and Religion in the Resettlement of Kosovar Mollica, Richard F. et al. Albanians.” Journal of Refugee Studies 15(2): 136- 2002 “Science-Based Policy for Psychosocial 152. Interventions in Refugee Camps: A Cambodian

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