Local, dynamic, flexible: healthcare provision in the refugee response

For Doctors of the World (DOTW) – also known as Médecins du Monde (MDM) – the response to the increase in refugee arrivals in Europe has effectively been a massive expansion of the work we already do with vulnerable people on the continent. As such, DOTW has seen refugees and migrants to Europe in our projects for many years. DOTW France has had a support and advocacy project in Calais for over a decade. However, as the number of people arriving in Europe started to rise significantly, the MDM network mobilised to support specific responses, in Greece especially (Lesvos, Chios, Piraeus, Athens, Idomeni and on ferries between islands and the mainland), in addition to starting new projects supporting local organisations or at registration centres in Serbia, the Former Yugoslav Republic of Macedonia (FYROM), Croatia and Slovenia. Today, the response has grown to 18 sites in Greece, primary health support in Belgrade and on the Serbia/ Hungary border, partnerships with local organisations in Slovenia and Croatia, a growing medical support programme in Calabria, Italy, and mobile clinic or support operations in Calais, Dunkirk, Caen and Dieppe in France, and Oostende and Zeebrugge in Belgium. We are also seeing refugees in our clinics in Belgium, France, Germany and the UK. This article highlights some of the distinct but related lessons we have learnt from the response.

Health provision

Health needs among the refugees are not particularly remarkable. However, our teams noted several observations in Greece and Calais. In Greece, roughly 36% of the patients seen were children, which correlates with estimates that one in three refugees arriving in Greece is under 18. Incomplete immunisation, inadequate safeguarding, lack of health promotion and lack of health screening, for instance for congenital conditions, is a major concern for this group. The combination of incomplete immunisations and cramped living conditions results in susceptible refugees developing diseases such as measles and varicella (chicken pox), a particular threat given their high incidence in some regions of the European Union (EU). Measles immunisation is often seen as a high priority in refugee settings due to the potential for immune-related complications such as pneumonia and diarrhoea. However, in this instance it took a long time for this to be organised, eventually being carried out largely by Médecins Sans Frontières (MSF), but also by state and other non-state actors.

It is worth considering why it took so long for vaccination to become a clear health action. The first, clear reason is that, until the EU–Turkey deal, we did not have the static population that would normally trigger a vaccination campaign due to the threat of outbreaks. However, we did have camp conditions where diseases would be present. Second, it is difficult to immunise a mobile population properly as coverage rates are difficult to confirm and double immunisations likely. However, without a static population and the risk of outbreak, it can be considered irrelevant to base operations on considerations of coverage. We are not vaccinating against an outbreak, but providing the individual with protection.

The most notable difficulty in health provision has been mental health support. The need for it is clear – not only are people leaving situations of extreme threat and the possibility of trauma, but the journey itself is full of stress and trauma. The ability to treat mental health problems is severely hampered by ongoing, uncertain movement. Incomplete or partial treatment could also risk causing further harm. Since the implementation of the EU–Turkey deal, in Greece and, for a longer period, in Calais, we have seen more profound issues as a result of the journey being halted, with an increase in aggressive behaviour, depression and suicide attempts. It is entirely predictable that, once people’s journey has been stopped, they lose hope unless they are engaged in some other form of action for their benefit. The slow process of asylum in Greece has led to feelings of frustration and powerlessness, while the conditions of camp life lead to boredom and loss of agency. Many organisations in Greece are now offering psychosocial interventions, including group discussions, art therapy and counselling, along with significant efforts by Internews especially to try to address some of the causes of frustration through better communication with and from camp residents. However, this is still a massive gap in the response, with wide-ranging implications for the asylum process and, if asylum applications are successful, for how well people are able to adjust to their new conditions.

Irrespective of the route taken, deprivation during the journey, poor living conditions and lack of adequate hygiene have increased vulnerability to respiratory conditions, gastrointestinal illness and skin diseases. Unsurprisingly, DOTW data from Northern France, the last barrier for many, shows that around 63% of health problems were related to living conditions and almost a quarter were musculoskeletal injuries. This is of course most concerning for patient groups with particular vulnerabilities – children, pregnant women, the disabled and those with existing conditions such as diabetes or other non-communicable diseases. Lack of access to, or perceived time to access, healthcare will result in increased morbidity and mortality. However, more also needs to be done to call on states to address terrible living conditions, in Northern France especially.

The value of local knowledge and presence

DOTW has run operations in Greece for the last 25 years and manages a network of five polyclinics across the country (in Athens, Perama, Thessaloniki, Chania and Patras). These are primarily for the local vulnerable Greek population, but all are welcome, and services are free. The polyclinics operate with volunteer doctors of different specialties (internists, paediatricians, surgeons, gynaecologists, dermatologists, cardiologists, ophthalmologists, orthopaedic surgeons, radiologists, pulmonologists, ENT, psychiatrists, neurologists), nurses, psychologists and social workers. DOTW Greece also runs social programmes, mobile clinics and research projects. The response to the increasing numbers of refugees arriving in Greece therefore grew from a well-established operation, and has been able to gain access to situations that other, larger INGOs could not through established relationships with local authorities or government ministries.

Having this backbone of polyclinics and established networks within the Greek medical community also allowed flexibility. Existing relationships with secondary care facilities and staff meant that DOTW was able to expedite referrals despite the need for translation and a lack of resources in the health system. As DOTW needed to scale up its work, our reputation locally made it easier to identify staff who also knew what DOTW did and the way that we work. This meant that we were able to recruit effective, inducted and informed teams quickly as temporary concentrations of people developed, particularly in Athens. The vast majority of staff, clinical and non-clinical, are Greek volunteers.

In Calais and Dunkirk the challenges were different. Our long-term programme there has involved assisting vulnerable people, often migrants or refugees, to obtain health care within the French national system. Our presence increased from a small team of seven or eight to over 40 volunteers as the Calais camp grew. Our services also developed to include running a clinic providing primary health care and referral support along with psychosocial assistance and information and cultural advice. Surge support was provided by volunteers from France and the UK. As in Greece, DOTW was able to negotiate access and action with local authorities where some larger INGOs could not because of the long-standing relationships it had established. However, it should be noted that we did not protect this relationship at the cost of access: following severe vandalism and destruction of our clinics by suspected far right groups, DOTW changed tack and successfully pursued legal action against the French authorities for failing to provide basic services to refugees and migrants. Winning this legal battle has been instrumental in improving basic conditions in Calais.

Dignity

One of the worst aspects of the situation in Europe has been the systematic dehumanising of the refugee population. This has manifested itself in many ways, most noticeably in politicians’ talk of ‘swarms’ and the development of policies that are designed to offer help, but only in distant places (with notable exceptions). In on the ground operations this can manifest itself in different ways. For DOTW, one noticeable issue has been the use of face masks and protective overalls. It has been our experience that many actors in Europe feel the need to protect themselves from a perceived risk of contamination. We have seen this on rescue boats in the Mediterranean and in registration facilities all along the Balkan route. This is an entirely unnecessary precaution, but one that strongly contributes to the narrative of ‘them and us’: a separation based on negative imagery of infection or contagion, that refugees are not people like us and that we need to take precautions, even when ‘helping’ them. (In fact, the risk is probably the reverse – refugees risk contracting vaccine-preventable diseases that the local population is immune to.) Quite apart from the effect on the public perception of refugees that media images present, DOTW is also very concerned about the psychological effect that presenting assistance in this form can have on the refugees themselves. Encouragingly, we were able to change this practice on a local level in Slovenia, where local health staff agreed to abandon face masks. We would encourage all humanitarian agencies to be vigilant for small actions such as this, in addition to higher-level policy advocacy.

Keep moving, at all costs

Most refugee or IDP responses tend to be mounted in places where the population will remain, or at least stop for a reasonable period. One of the major challenges when working with refugees along the Balkan route, at least until the change in circumstances brought about by the European Union (EU)–Turkey deal in March, was that agencies were trying to intervene while people were still on the move.

Trying to assist people while they are on the move makes provision of services difficult for several reasons. From a health perspective, it makes continuity of care virtually impossible because the primary concern for refugees is to keep moving and there is no time for follow-up appointments or referrals. This has resulted in people walking out of consultations if they receive a message that a border may open, or people missing follow-up appointments. More seriously, we have also seen situations where parents would not allow a child to be referred to hospital, as the opportunity cost of spending time in hospital is perceived to be too high. This is not to imply that people are ignorant of the importance of healthcare; indeed, refugees have repeatedly told us how much they value it. The point is that it is less important than completing the journey. This is also apparent when you consider the other risks to life that people have been willing to accept, from being smuggled across the Mediterranean to hanging on to the bottom of trucks in Calais.

DOTW responded to this problem by analysing people’s situation at different points along their journey. Although the context was always changeable, we searched for particular times when refugees considered themselves at rest, and with no need to move. Finding these periods would allow refugees to engage with a service more, enabling us to deliver a more compassionate response of higher quality. Rather than expecting that refugees would avail themselves of services at the cost of their onward movement, this approach changed the way we considered where services should be established.

However, the list of suitable intervention points under these criteria was startlingly short. Even when going through registration processes or waiting for transport, refugees were constantly looking for any opportunity to move on. One intervention point that DOTW did identify was the ferry journey between the Greek islands and the mainland. Despite only being an overnight trip, providing services to people on the ferries was more effective, and provided a markedly different environment in which to manage both clinical and psychosocial consultations. Catching people when they were at rest, and providing services to them in this state of mind, allowed a measure of dignity in the process that other sites would not have made possible. Individual interaction was much easier, and people were more willing to open up. Providing time to talk about problems resulted in greater awareness of chronic conditions and the impact of lack of access to primary health care, along with getting an idea of people’s mental state.

Contrast this with the situation many hundreds of miles away, in Calais and Dunkirk. Here, we repeatedly see people who have not moved for months, but are very resistant to anything that may tie them down for any time at all, including hospitalisation for severe conditions. We manage to refer patients for injuries that will prevent them from moving on, such as a broken leg, but face refusal for potentially more serious conditions that are not immediately so debilitating. Despite being in a position where they have not moved for months, we repeatedly see evidence that taking time to address health needs which could cost an opportunity to move on is a risk people are not willing to take. Opportunity costs count for this population.

Gareth Walker is International Programme Manager at Doctors of the World UK.