Doctors Without Borders/Médecins Sans Frontières (MSF) continued to provide medical assistance to refugees and migrants along the Central Mediterranean route throughout the last months of 2017. At sea, the dedicated search and rescue vessel Aquarius, run by MSF in cooperation with humanitarian organization SOS MEDITERRANEE, rescued 3,645 people from unseaworthy boats in the Mediterranean and brought them to ports of safety in Italy.
At disembarkation, MSF provided psychological first aid after tragic rescues in addition to running several mental health and health care projects in Sicily. In Libya, MSF teams provided medical assistance to refugees and migrants arbitrarily held in detention centers nominally under the control of the Ministry of Interior.
Libya: Dismal Conditions in Detention Centers Hinder Medical Treatment
In Tripoli, a massive increase in the number of people detained in October and November 2017 resulted in extreme overcrowding and a dramatic deterioration of conditions inside the capital’s detention centers. In some locations, up to 2,000 men were crammed together in one cell without enough floor space to lie down.
Not only did overcrowding make it physically impossible at times for MSF teams to enter the cells and triage the people detained inside, it further increased tension and violence. MSF team members were harassed and threatened, and patients experienced violence and mistreatment. From September to December 2017 the MSF team treated more than 76 people for violence-related injuries, including broken limbs, electrical burns, and gunshot wounds.
The team was able to help only a small percentage of all those in need of urgent treatment and it was not possible to follow up on medical cases. Even so, more than 6,500 medical consultations in detention centers were carried out from September to December 2017.
Most medical complaints were related to the conditions of detention, with overcrowding and inadequate latrine and drinking water provision resulting in acute upper respiratory tract infections, musculoskeletal pain, and acute watery diarrhea. MSF teams tried to focus on the most vulnerable people, such as pregnant women, children under five years old, and people with life-threatening or potentially life-threatening complaints. A 24-hour emergency referral service was implemented, with more than 150 patients referred to hospital for further medical treatment.
The number of detainees dropped in December when thousands of people were repatriated to their countries of origin by the International Organization for Migration (IOM). Conditions inside detention centers in Tripoli improved and there was less mistreatment and violence against patients. In the detention centers that MSF visits, teams are now able to access cells to provide medical care to refugees and migrants that remain in arbitrary detention. However, most of the physical and mental health problems requiring medical assistance still stem from the substandard detention conditions.
Few international organizations are able to work in Libya due to widespread violence and insecurity. Those who do—including MSF—do not have full and unhindered access to all detention centers where refugees and migrants are being held. It is not possible to provide meaningful medical care in a system of arbitrary detention that causes harm and suffering.
An overwhelming number of detainees have already endured alarming levels of violence and exploitation in Libya and during harrowing journeys from their home countries. As such, MSF reiterates its call for an end to the arbitrary detention of refugees, asylum-seekers, and migrants in Libya.
Aquarius Continues Sea Rescues as Numbers Attempting Mediterranean Crossing FallIn the central Mediterranean, the number of refugees, asylum-seekers, and migrants rescued at sea and brought to safety in Italy has fallen since last year. The search-and-rescue ship Aquarius recovered 3,645 people from September to December 2017, compared to 5,608 during the same period in 2016.
This drop in numbers appears to be due to fewer boats leaving Libya. Reasons for this are unclear, though likely factors include the weather and political developments on the ground in Libya. There have been media reports that local militias are being paid off by Italy to prevent departures. Italian ships have been deployed in Libyan territorial waters as part of a broader European strategy to seal off the coast of Libya and “contain” refugees, asylum-seekers, and migrants in a country where they are exposed to extreme and widespread violence and exploitation.
Onboard Aquarius, MSF medics treated people for injuries they suffered in Libya and heard their accounts of violence and abuse at the hands of smugglers, armed groups, and militias. Around 12 percent of all women rescued were pregnant and were cared for by an MSF midwife. There was a high prevalence of severe skin infections that required treatment with antibiotics and many patients suffered from severe chemical burns.
As winter approached, teams also treated multiple cases of hypothermia among those rescued. Rough sea conditions caused huge swells to crash over the aft deck of the ship, soaking people sleeping there. In November, 588 people were rescued but an unknown number drowned after an overcrowded inflatable dinghy suddenly capsized mid-rescue. The team on Aquarius launched all available floatation devices and life jackets and pulled as many people from the sea as they could, but it was not possible to save everyone. No bodies were recovered.
A Challenging Rescue Environment, and An Unclear Future for Refugees
Carrying out search and rescue activities in the Mediterranean is becoming increasingly challenging and complex. People who manage to escape Libya are increasingly being turned back at sea, with the EU-supported Libyan Coastguard active in international waters. The MSF team on Aquarius witnessed refugees and migrants aboard unseaworthy vessels being intercepted by the Libyan Coastguard in international waters as EU military assets at the scene looked on. On October 31, November 24, and December 8, Aquarius was instructed to stand by and the crew was forced to watch as hundreds of people were pushed back to Libya by the Libyan Coastguard.
Although these interceptions are presented as “rescue operations” and are celebrated by the Libyan Coastguard and their EU partners, the reality is that migrants and refugees are not being returned to a port of safety. The crimes committed against refugees and migrants in Libya are widely known and have generated international outrage. Under no circumstances should migrants and refugees aboard vessels in distress in international waters be returned to Libya—they must be brought to a port of safety.
In September, Aquarius was instructed to conduct three rescues in international waters under the coordination of the Libyan Coastguard. These unprecedented and highly unusual instructions from the Maritime Rescue Coordination Center (MRCC) in Rome presented MSF with an impossible choice. Fortunately for each rescue, Aquarius was able to render the necessary assistance and took all rescued men, women, and children to a port of safety in Italy.
In that situation, it was not possible to verify who exactly was coordinating rescue operations, as there are several entities operating along Libya’s vast coastline that claim to be the Libyan Coastguard. Contact points on land and at sea were unclear, as was the chain of command. As there have also been numerous violent incidents in recent months between the Libyan Coastguard and the few other remaining humanitarian organizations running dedicated search and rescue activities in the Mediterranean, the security of our team was paramount during these interactions.
It’s unclear what the future holds for refugees and migrants traveling the Central Mediterranean route, but with Libya riven by widespread violence and insecurity, with no unified government, a plethora of armed groups, and active fighting ongoing in several parts of the country, it does not look like an end to their suffering is in sight.
MSF has worked in Libya since 2011, providing medical consultations and referrals to refugees and migrants held in several detention centers nominally under the control of the Ministry of Interior. MSF works in centers in Tripoli, Khoms, and Misrata and, in partnership with a local association, provides care to those who have survived and managed to escape from informal places of captivity in the Bani Walid area. MSF also runs a primary health care clinic in Misrata and supports women and child health activities in Benghazi.
Published on MSF on January 30, 2018
By Fahrinisa Oswald
Already traumatised by loss and conflict, stranded refugees face further trauma without mental healthcare.
Athens, Greece - It was just another day for teenage brothers Ismael and Isa Achekzai at the local market in Herat, Afghanistan, where they went daily to sell potatoes from their family's modest plot of land on the outskirts of town. Their earnings from the market were not much, but they were enough to help the family of five just about get by.
But as the brothers pushed their wheelbarrow towards their home, a powerful explosion ripped through the market, leaving behind a cloud of dust and chaos, and a family who would forever be changed.
As the debris began to settle, Ismael stood up and looked to the spot where his brother had been standing just moments before. The wheelbarrow carrying their vegetables was overturned, its contents a splattered mess everywhere. Isa had not survived the blast from the roadside bomb.
Bending down slowly, Ismael started collecting his younger brother, piece-by-bloody-piece. He collected as much of Isa as he could find, placing the pieces in a plastic bag. He then carried the bloodied plastic bag home, placing it on the kitchen table for his mother who was busy making dinner. That was 10 years ago.
"Ismael has not been the same since," says his father, Ibrahim Achekzai, who is now in his mid-50s. Neither has his mother, who recently gave birth to a premature baby boy in a camp on the outskirts of Athens, Greece. Though she claims to be in her mid-30s, Bibi Achekzai is missing almost every tooth in her mouth and has the appearance of a woman in her late-40s.
The Achekzais are one of thousands of traumatised refugee families now stranded in Greece since the beginning of the mass influx of refugees to Europe in mid-2015.
They are also one of the many refugee families in desperate need of mental health services, which, though exist in small numbers, are incredibly difficult to access.
Prior to the ratification of the EU-Turkey deal on March 20, 2016, very few refugees who arrived in Greece stayed for more than a few days or weeks. With the EU-Turkey deal, however, followed by the closure of the Macedonia border and the Balkan land route to central Europe, more than 62,000 refugees from Syria, Iraq and Afghanistan are now stranded in Greece, a large percentage of whom are in desperate need of mental health services.
The EU-Turkey deal and the sudden closure of the Greek-Macedonian border meant that many people who had planned on continuing onwards to central and northern Europe were forced to quickly reassess their plans. Not only did this cause chaos in the asylum system in Greece - by suddenly overloading it with thousands more cases over night - it created a fresh trauma for many refugees whose futures became instantly uncertain.
"It was really abrupt what they did," explains Anastasia Papachristou, who works for Doctors Without Borders (known by its French initials MSF). "They just stopped their movement and the majority of our patients had to plan their lives all over again." Because of this, she continues, "they experienced yet another trauma."
'We share patients'
Since 2014, MSF has run a joint programme with Babel DC - a local Greek NGO that offers mental health services and support to the refugee and migrant community currently stuck in Greece. "We share patients," says Anastasia.
"They [Babel] have a psychiatrist on their team and they provide psychological services to our patients and we cover the holistic rehabilitation of them."
Between the two organisations, refugees and migrants who have access to these services have "full support: social, psychological, medical and mental support," says Anastasi.
For the first 10 months in Greece, the Achekzai family lived in a camp in Oinofyta, a small town on the outskirts of Athens.
Despite the camp manager's continuous attempts to relocate them to central Athens where they would be able to access mental health services for Ismael and Bibi, and school for the younger son Yacoub, 16, the cries for help fell on deaf ears. For 10 months, the family sat in their tent day after day, with little clarity about their asylum process, and unable to begin a rehabilitation programme - further traumatising the entire family.
"Because of the living conditions here in Greece, the lack of safety and clarity about their asylum cases, they [the refugees] are being re-traumatised and rehabilitation takes longer. We have a lot of relapses," explains Anastasia.
In January 2017, 10 months after their arrival in Greece, the Achekzai family was finally identified as highly vulnerable and moved to an apartment in central Athens where Ismael and Bibi would have access to much needed mental health services.
"The UNHCR gave us a list of seven points of vulnerability - these are seven vulnerabilities we are looking for in a person," explains Lisa Campbell, the manager of the camp in Oinofyta where the Achekzai family was living. "In the end, in the Achekzai family of five people, there were 20 vulnerabilities - multiple vulnerabilities per person."
The Achekzai family are only one of the many cases that mental health practitioners are now facing in Greece. More and more they are dealing with problems directly caused by the increasingly desperate plight of refugees stranded in Greece.
"Because we don't have the right social services and psycho-social services available, people are getting severely depressed. People are turning to alcohol and drugs, spousal abuse and violence," explains Lisa. And the longer they sit in the camps with nothing to do and no clarity about their situations, the worse the problem gets.
"For those who have been so traumatised - either by war, by the trip or by sitting here for the last seven, eight, nine months - some of them over a year - in hopelessness without the support system that they need, they are turning to things that are going to be detrimental to society," she continues.
Mental health and rehabilitation services
The most recent case that Campbell referred to a mental health unit in her camp was of an Afghan woman who had been there for several months, was eight months pregnant, and was becoming near suicidal. She was so depressed that she had become violent towards her own family, shouting at her husband and son on a daily basis. Out of pure desperation, the husband reached out to Lisa for help, and she was able to make a referral immediately.
According to Lisa, European politicians may be "shooting themselves in the foot" by not addressing the mental health issues of the current refugee population in Greece as well as throughout the rest of Europe. "They are going to try to integrate into European society and they are not going to have the coping skills to do what they need to do to become productive members of society," she says.
But, offering mental health support and rehabilitation is complex, time-consuming and expensive, and the challenges that organisations and practitioners face are enormous. "There are challenges linked to the specific problems with which they come to us, and these are very complex problems - problems that have come with them from their country of origin," says Nikos Gionakis, president of Babel DC, a Greek mental health unit for migrants and refugees.
"Other [challenges], relate to the way they have moved, and many of them are related to the conditions of living here, from lack of perspective and lack of information about their situation," he continues.
There are also cultural challenges relating to the stigma of seeking mental health support. "When people come from countries where the mental health system is stigmatised - for example, it is identified with big mental hospitals - people believe many times that if they go to a psychiatrist they will end up in a mental hospital," says Nikos.
They are very reluctant, he adds, and it often take months to build trust to the point that these people are able to open up about the trauma they have experienced or are currently experiencing.
Due to the heavy nature of the work, Babel also offers mental health support to volunteers and professionals working with refugees and migrants. "We say that in order to care for someone, someone else must care for you," says Nikos.
Mental health and rehabilitation services will not bring back Ismael's younger brother, Isa. It may not even be able to improve Ismael's condition. But, for Isamel and Bibi - and for the thousands of refugees like them - it may help to prevent further trauma. It may even provide them with better and more effective coping mechanisms.
"It's a complex thing for us," says Anastasia. "Rehabilitation is not that you can focus on one thing. You need to have a holistic approach, so you need to follow their progress throughout the whole rehabilitation process. You have to focus on their total improvement."
This article was published on Al Jazeera's website on March 22, 2017.
One year after the EU-Turkey deal: migrants and asylum seekers are paying the price with their health
One year after the EU-Turkey Deal, Médecins Sans Frontières (MSF) released a report to expose the human costs of European policy failures in Greece and the Balkans. MSF calls on the EU and member state leaders to radically change their approach to migration and ensure a swift end to the unnecessary suffering of the thousands caught in the consequences of the EU-Turkey deal.
The European Council stated that the deal, which rewards Turkey for “stemming the flow” of migrants and refugees and accepting those forcibly returned from Greek shores, would offer migrants “an alternative to putting their lives at risk”. One year after, men, women and children are trapped in unsafe zones outside Europe, unable to flee, forced to use even more dangerous smuggling routes to reach Europe, or they are trapped in overcrowded “hotspots” on the Greek islands.
“The deal is having a direct impact on the health of our patients, and many are becoming more vulnerable,” says Jayne Grimes, MSF psychologist in Samos. “These people have fled extreme violence, torture and war and survived extremely dangerous journeys. Today, their anxiety and depression is aggravated by the lack of information on their legal status and their poor living conditions. They are losing any hope that they will find a safer, better future than the one they fled. I often see people who contemplate suicide or self-mutilate.”
According to the report “One Year on From the EU-Turkey Deal: Challenging the EU’s Alternative Facts”, MSF psychologists in Lesvos saw the percentage of patients with anxiety and depression increase by two and a half and the percentage of those with post-traumatic stress disorder increase threefold. Symptoms of psychosis also increased. This all coincides with our teams seeing more patients with severe trauma, and more cases of self-harm and suicide attempts. Through the nearly 300 mental health consultations MSF teams in Samos have conducted, they have seen a similar deterioration and an escalation in self-harm and suicide attempts in recent months.
“European leaders continue to believe that by building fences and punishing those who still try to cross them, they will deter others from fleeing for their lives,” says Aurelie Ponthieu, MSF humanitarian adviser on displacement.
Along the Balkan route in Serbia and Hungary, MSF teams have seen an increase in patients reporting trauma linked to the violence they have experienced since the closure of the Balkan route, a few days before the EU-Turkey deal.
“European leaders continue to believe that by building fences and punishing those who still try to cross them, they will deter others from fleeing for their lives,” says Aurelie Ponthieu, MSF humanitarian adviser on displacement.
“Every day we treat the wounds, both physical and psychological, inflicted by these deterrence policies. Such measures have proven to be not only inhumane and unacceptable, but also completely ineffective,” concludes Ponthieu.
MSF decided to suspend funds from the EU and Member States in opposition to the EU-Turkey deal. We reiterate that full respect of the right to seek asylum, the opening of safe and legal alternatives for the movement of people, such as resettlement, relocation, humanitarian visas and family reunification, as well as work and study visas are the only humane solution to end death and suffering at Europe’s borders, on land and at sea.
This article was published on Médecins Sans Frontières' website on March 14, 2017.
Despite mounting evidence of inhumane treatment faced by Eritreans, in and outside Eritrea, the EU is doing all it can to prevent them reaching its shores, says a new report.
The report is based on hundreds of conversations and 106 in-depth testimonies from Eritreans who have fled their country. In MSF’s medical projects in Libya, Ethiopia and on its rescue boats in the Mediterranean, Eritreans arrive almost every day with wounds, heavy scarring and other medical conditions, including severe psychological illnesses, that are consistent with their testimonies.
Every Eritrean interviewed by MSF teams on its search and rescue vessels in the Mediterranean Sea reports being either a direct victim or a witness to severe levels of violence, as well as being held in captivity of some kind. More than half report having witnessed the deaths of fellow refugees, asylum seekers or migrants, most often as the result of violence.
Every Eritrean woman interviewed has either directly experienced or knows someone who has experienced sexual violence, including rape, often inflicted by multiple perpetrators.
It is illegal for Eritreans to leave the country without an exit visa, which are notoriously difficult to obtain. Those who are able to escape face extended periods in refugee camps in neighbouring Sudan and Ethiopia; physical, psychological and sexual violence; arbitrary detention and deportations in Libya; and dangerous sea crossings to Europe – a crossing which claimed the lives of at least 4,500 people in 2016 alone.
Rather than developing safe and legal routes for those seeking international protection, the EU is increasingly collaborating with Eritrea, Libya, Sudan and Ethiopia to prevent Eritreans from leaving Eritrea and transiting through these countries to reach Europe.
The EU’s attempts to stem migration through strengthening national borders and bolstering detention facilities outside its borders leave people no choice but to pay smugglers to get them past checkpoints, across borders, through fences, out of prisons and ultimately onto boats on the Mediterranean Sea.
Vickie Hawkins, MSF UK Executive Director: “It is vital that the UK government provides channels to safety for Eritreans, and indeed all people fleeing conflict and persecution. Efforts to manage migration should not externalise border controls to unsafe countries - wherever they may be.
"Given the UK Prime Minister’s commitment to lead a ‘truly global Britain which reaches beyond Europe’, the UK must lead by example in ensuring vulnerable people who are in need of asylum are able to seek it safely. MSF insists that people seeking protection must not be abandoned or left trapped in unsafe places, with no option but to risk their lives on a perilous journey.
"Containment is not the answer; UK policies should never trap or force people into danger. Appallingly, current policies do just that”.
This article was published on One World News' website on February 27, 2017.
The MSF report is available below.