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Europe’s Refugee Crisis: An Unresolved Humanitarian Emergency

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Some definitions

Asylum seeker: A person who has fled their country and has applied to another country for recognition as a refugee but has not yet been granted this status.

Refugee: Someone whose asylum application has been successful. The government recognizes they cannot return to their country of origin owing to a well-founded fear of being persecuted for the reasons provided for in the United Nations Refugee Convention or European Convention on Human Rights (such as persecution due to race, sexuality, political opinions, or religion).

Undocumented migrant: Someone who enters or stays in a country without the documents required under immigration regulations. They usually have no recourse to public funds or governmental support.

Refused asylum seeker: A person whose asylum application has been unsuccessful. 

Introduction

Whilst our news headlines may no longer include pictures of rubber dinghies arriving on the shores of the Mediterranean, the migrant crisis persists and continues to deteriorate. Numbers arriving in Greece in the first quarter of 2024 were the highest they have seen since 2019.

Nearly 50,000 undocumented migrants and asylum seekers have arrived in Greece by land or sea since September 2023, mainly across the Evros land border and the Greek islands. This data represents only those registered. Some go undetected as they try to make their way further into Europe. In the Greek islands, 4,115 arrivals were registered in May 2024 compared to only 1,592 in May 2023, with numbers currently staying in refugee camps in Greece almost double that of the same time last year.

Not only are numbers higher, but the provision of services and services for those arriving is becoming increasingly stretched. In June 2024, Greece’s National Public Health Organization (EODY) unexpectedly announced the termination of its health intervention program in all Greek refugee camps starting in July. This decision leaves residents without access to essential healthcare until the new Hippocrates program begins in mid-September.

During this two-month gap, thousands of individuals will face a critical shortage of medical care amidst overcrowding and deteriorating hygiene conditions. The only available healthcare during this period will be through NGO organizations, civil society groups, and NGOs such as Medical Volunteers International.

Last year, I served as a senior clinician with Medical Volunteers International (MVI) in Greece, collaborating with an international multidisciplinary team of doctors and nurses to provide medical care to displaced individuals in refugee camps and those on the move. Although I was keenly interested in this field, my experience with refugees and working outside the NHS was limited. The reality of the ongoing crisis, with its complexity and scale, was more challenging than I had anticipated.

Patient demographic

The demographic of undocumented migrants and asylum seekers arriving in Greece is broad. The graph below depicts the arrivals in 2024, which also represents the demographic of patients seen in MVI clinics, with patients largely from Afghanistan, Syria, Iraq and African nations such as Sierra Leone, Congo and Somalia.

Fig 1. Nationalities of sea arrivals in Greece 2024. UNHCR.

In 2023, MVI conducted 2994 consultations, of which 16% were children. MVI offers essential outreach services to refugee camps as well as operating a central clinic in Athens, providing undocumented migrants, refused asylum seekers, and the homeless with regular medical care. Almost all individuals arriving in Greece have endured arduous and prolonged journeys. Many children come from countries with limited access to healthcare, devastated infrastructure, and ongoing armed conflict. As a result, their healthcare since leaving their country of origin has frequently been unreliable or non-existent, leading to missed or poorly managed chronic health issues.

A review of the consultations conducted by MVI in 2023 revealed that the most common presenting complaints were similar to those of children in the UK, namely upper respiratory tract infections, coughs, ENT infections and viral gastroenteritis. However, presentations of malnutrition, scabies, lice, poor growth, and social and behavioural concerns also created a high workload. Chronic conditions such as asthma, eczema and congenital heart defects also featured and were difficult to manage due to the severity of symptoms children were experiencing by the time they reached Greece.

During my own time in Greece, I saw a 15-year-old girl from Syria who had such severe untreated idiopathic scoliosis that it had compromised her breathing and significantly limited her mobility, as well as the case of a man in his early 20s who had received no repair of his congenital heart defect in his home country, only for his asylum to be refused in Greece leaving him in end-stage heart failure with no entitlement to surgical intervention.

Fig 2. Presenting complaints for children (<18yrs) seen by MVI 2023

Challenges for medics on the ground

Providing medical care in refugee settings presents numerous challenges. The World Health Organization’s 2018 policy brief, “Health of Refugee and Migrant Children,” emphasizes the importance of a comprehensive and individualized health assessment for all refugee and migrant children upon arrival in the country of asylum. In practice, however, such assessments are often inconsistent, with many children only receiving medical attention if their parents actively seek it out through camp doctors or NGOs.

With a team made up of mostly European doctors who speak primary English and German, the differences in language and cultural beliefs between MVI volunteers and asylum seekers/refugees are often vast.

The settings where care is provided vary widely—from well-equipped clinic rooms in Athens to makeshift shelters under canopies in the midday sun at refugee camps. Privacy and dignity can be challenging to maintain in these conditions. For example, Ritsona, Greece’s largest refugee camp with over 2,000 residents, restricts MVI’s access, forcing them to work outside the camp’s high concrete wall, which the Greek government claims was erected for security reasons but contributes to an environment which more resembles a prison than a temporary housing solution.

Most patients lack medical records, so documentation of previous investigations, management, or surgery is limited to what they tell you. Without the extraordinary team of translators, most doctors would be working completely blind.

MVI’s team of translators consists mostly of asylum seekers, refugees, or refused asylum seekers who are going through an appeal process themselves. Many speak up to five languages and have accumulated good medical understanding through their work. All of them are on a journey to establish a new life themselves but find purpose and community through their voluntary work with MVI. Despite their expertise, the language barrier is still challenging, making consultations longer and establishing patient-doctor rapport more difficult.

Once patients’ symptoms have been outlined, investigations prove even more difficult, usually referring people long distances to clinics or hospitals for imaging, bloods and specialist opinions. Most refugee camps provide minimal, if any, public transport options into the cities, with camps like Ritsona situated a staggering 80km north of Athens. Patients must fund these journeys themselves as NGOs are unable to provide patient transport due to laws around the movement of asylum seekers and refugees. Once referrals are made, very few hospitals arrange translators. Therefore, many consultations happen with minimal patient understanding, and patients bring back clinic letters or prescriptions in Greek for MVI to translate.

MVIs team of doctors and nurses has a relatively fast turnover with the average doctor staying only four weeks. This makes consistency for patients difficult, despite weekly handover meetings and case-based discussions to try to mitigate this impact. Even the most resilient and experienced clinicians would be affected by the stories you hear, the journeys undertaken, and the suffering experienced – whilst the charity offers and encourages psychological support, the cases will inevitably stay with you. Safeguarding processes for patients exist but are challenging to navigate, and several women I saw hinted at abuse, including sexual and physical violence, but were reluctant to take this further than accessing psychological support.

For refused asylum seekers, the outlook becomes even more bleak. Refusal of asylum leaves many patients without any access to state-funded healthcare, and they are left entirely at the mercy of NGO organisations such as MVI and MSF. Approximately 40% of asylum applications in Greece are initially denied, often due to difficulties in providing sufficient evidence. Appeals can take years, when applicants cannot legally work, pursue education, or support themselves and their families.

How is this relevant to us as paediatric ED clinicians?

We’re not all going to work in refugee camps in Greece, BUT many of us work in countries where we are very likely to encounter an asylum seeker, refugee, or undocumented migrant in a hospital at some point in our careers. In 2023, 67,337 applications for asylum were recorded in the UK.

There are very few legal ways to enter the UK openly. Therefore, many enter the country illegally, including the 29,437 people who arrived on small boats last year. Individual circumstances differ widely; some people may enter the UK on a valid visa but later be unable to return due to political changes in their home country, or they may be trafficked into the UK against their will. In 2023, there were 3,412 applications from unaccompanied children (under 18 years of age), with 75% being granted asylum and five children being granted short-term leave to remain. Afghanistan was the top country for applications of unaccompanied children in the last 12 months.

Just like clinicians working for MVI in Greece, clinicians seeing these patients in an acute hospital setting elsewhere must consider several things before completing their consultation. The BMA has published and recently reviewed a comprehensive resource around refugee and asylum seeker health in the UK, available for all health professionals treating these patients in clinical settings.

Medical implications

  • The first and possibly most important part of your consultation is to ensure good translation if your patients do not have a confident understanding of English. Ask specifically about the preferred gender of the translator, language and dialect. For example, it may not be appropriate to use an interpreter who is from an ethnic or political group that has been involved in violence or oppression in the patient’s country of origin, as this may undermine trust.
  • To establish rapport, maintain eye contact with patients while taking a history despite using a translator.
  • Remember, chronic conditions may have been poorly managed, with patchy, if any, advice given to parents. Medications may have been changed regularly, missed, or taken incorrectly. For example, many parents/patients may not understand what asthma is or how to treat it despite telling you they/their child has it.
  • Always consider the possibility of untreated infectious diseases such as TB, HIV and Hepatitis. Ensure good counselling of patients before testing for these, as the likelihood of a positive result is higher than in the general population.
  • Due to crowded living conditions and poor access to sanitation during patients’ journeys, the chances of scabies, lice, and bedbugs are high. If patients have recently arrived, try to examine their skin, nails, and scalp even if this is not their presenting complaint.
  • Vaccinations are likely to have been patchy, if not missed entirely. Ensure patients know how to access catch-up vaccinations via their GP and appreciate the increased likelihood of these diseases when considering differential diagnosis.
  • Consider the lack of antenatal and postnatal care for pregnant women coming from countries with unrest, lack of infrastructure or conflict. This could have led to missed antenatal ultrasound scans, TORCH/postpartum infections and identification of congenital abnormalities at newborn baby checks.
  • Developmental milestones are unlikely to have been checked or considered later than children living in the UK since birth. Always ask about developmental milestones as part of any initial assessment.
  • Consider FGM in adolescent girls. A full map of countries and the prevalence of FGM can be seen on the National FGM Centre website. (A free e-learning module on FGM, developed by Health Education England, is available for all UK doctors)
  • Rates of torture, sexual abuse, domestic abuse and human trafficking are extremely high amongst the refugee population. Know your competence limits when talking about and assessing this, but also know who to refer to in your organisation should you have concerns or your patient requires further support.

Social implications

  • In the UK, while awaiting a decision, asylum seekers only have access to an allowance of £5.39 a day per person from the Home Office, often in the form of vouchers or on a pre-paid card. This can make managing everyday demands such as food, prescriptions, sanitary products and phone credit difficult.
  • During this period, asylum seekers are at risk of health problems linked to poverty, such as malnutrition. Extended periods of stress and uncertainty can also lead to declines in mental health. Due to cultural differences, many patients may find this particularly difficult to talk about or feel ashamed of their psychological distress.
  • Home Office accommodation and financial support end 28 days after an asylum claim is approved. Local Authorities are then responsible for housing new refugees; however, benefits can be delayed, and new refugees are at considerable risk of being made homeless.
  • Patients who need to attend frequent appointments may have difficulty paying for transport. This is particularly important to explore if you are referring for investigation or further consultations. Local schemes may help vulnerable patients reach appointments; it is worth knowing whether these are available in your area. The NHS Low Income Scheme or local charities may also be able to assist.

Conclusion

The ongoing refugee crisis in Greece presents a complex challenge, intertwining humanitarian, medical and political concerns. Whilst NGOs and civil society groups are providing some essential healthcare services to asylum seekers and refugees, the situation remains extremely precarious due to strained resources, inconsistent funding and the continuous influx of individuals seeking asylum.

Addressing the medical needs of this vulnerable population requires a sustained, collaborative effort from international organisations and local governments/authorities. As the crisis persists, it is crucial that health systems adapt to build long-term, resilient healthcare solutions capable of responding to its ongoing nature.

As clinicians, we need to consider the implications of this crisis in our own countries. This includes understanding the unique and complex health issues refugees face and ensuring we are equipped to handle these patients’ challenges.

References

United Nations High Commissioner for Refugees (UNHCR). (2024). Mediterranean situation. UNHCR. Situation Mediterranean Situation (unhcr.org)

EfSyn. (2023)Εργαζόμενοι και πρόσφυγες σε απόγνωση από κοινού. Εφημερίδα των Συντακτών. https://www.efsyn.gr/ellada/ygeia/437052_ergazomenoi-kai-prosfyges-se-apognosi-apo-koinoy

Medical Volunteers International. (n.d.). Medical Volunteers International: Providing medical care to refugees and migrants. Retrieved from https://medical-volunteers.org

World Health Organization (WHO). (2023). Health of refugee and migrant children: Policy brief. Retrieved from https://www.who.int/publications/i/item/health-of-refugee-and-migrant-children-policy-brief

Al Jazeera. (2021). Concrete walls and drones: Greek plans for refugee camps decried. Refugees News. Retrieved from https://www.aljazeera.com/news/2023/8/7/concrete-walls-and-drones-greek-plans-for-refugee-camps-decried

Refugee Support Aegean (RSA). (2024). Refugee camps in mainland Greece. Retrieved from https://rsaegean.org/en/refugee-camps-in-mainland-greece/

Suleimenova, S. (2023). Inside Greek refugee camp Ritsona’s mission to ‘safeguard human rights’. Harbingers’ Magazine. Retrieved from https://www.harbingersmagazine.com/inside-greek-refugee-camp-ritsona/

House of Commons Library. (2024). Asylum seekers and refugees: Key statistics. Retrieved from https://commonslibrary.parliament.uk/research-briefings/sn01403/

 British Medical Association. (2019). Refugee and asylum seeker health resource. Retrieved from https://www.bma.org.uk/media/2086/bma-refugee-and-asylum-seeker-health-resource-june-19.pdf

The BMJ. (2022). Initial health assessments for newly arrived migrants, refugees, and asylum seekers. The BMJ. https://doi.org/10.1136/bmj-2021-068821

National FGM Centre. World FGM Map. Retrieved from https://nationalfgmcentre.org.uk/world-fgm-map/

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