MSF and migration

1. The impact of detention practice on migrants’ health and wellbeing: the experience of Médecins Sans Frontières in Greece.

2. MSF and migration • MSF has a long history working with refugees and internally displaced, since the 1970’s.In addition, since the late 1990s, MSF has intervened in host countries (Spain, Belgium, France, Italy, Greece) and “transit” countries (Morocco, Yemen, Egypt, Mexico) to address vulnerabilities caused by increasingly restrictive immigration policies. • As a humanitarian organisation MSF respondsto human beings in need of assistanceirrespective of their legal status. MSF’s commitment to assisting populations on the move stems from their accummulated vulnerability at different stages of the migration process. This is considered by MSF a crisis where life, health and human dignity are being put at risk.

3. Restrictive immigration policies • A wide range of restrictive immigration policies have increasingly been put in place in Europe over the last decade. These include stricter border controls and interception measures; cooperation and readmission agreements with countries of origin and transit; increased and prolonged use of detention. • EU Return Directive increased the maximum detention period at 18 months (for foreigners subject to return). • However several European countries apply systematically the practice of immigration detention not only for migrants “subject to return” but also for migrants and asylum seekers upon arrival.

4. MSF interventions • Since 2004, MSF has provided medical and psychological support to migrants in detention centres across Europe: in Greece (2008– now), Malta (2008-2010), Belgium (2004-2007), and Italy (2012). • The medical and humanitarian situation of migrants in detention is worrying across settings: Serious barriers to access healthcare, including mental healthcare, overcrowded living conditions, combined with inadequate sanitation facilities, lack of provisions for vulnerable groups.

5. MSF interventions in Greece MSF intervention in Greece 2008- up to now • Medical care • Psychological support • Identification of vulnerable cases • Humanitarian assistance (provision of personal hygiene and other emergency items) • Awareness and advocacy activities/Lobbying authorities to ensure acceptable detention conditions and medical services.

6. Medical Emergency Project in Border Police Stations (Dec.2010- Apr.2011) 1,809 patients – 32 referrals to secondary care In addition 75 patients received psychological support in 122 individual mental health sessions – 11 referrals to psychiatric care Patients: 89% male of whom 5.9% minors, 11% female Main countries of origin: Afghanistan, Iran, Iraq Pakistan, Baglandesh Somalia, Northern Africa

7. Impact of detention on physical health • Upper respiratory tract infection (18.7%), lower respiratory tract infection (7%), non-bloody diarrhoea (8.3%), musculoskeletal condition (10.9%), skin infections (5.3%), headaches (4%). • In total 63% of total diagnoseswere linked directly or indirectly to the substandard detention conditions: overcrowding, lack of hygiene, water and sanitation problems, lack of ventilation and no possibility to spend time outdoors.

8. ECDC field visit report, 2011 “The main problem is the increased risk for communicable diseases in the detention centers, mainly linked to severe overcrowding, lack of hygiene, lack of basic supplies (e.g. blankets, shoes, soap, etc.), lack of the possibility for outdoor activities and the long duration of detention. The conditions in the centers are below the internationally accepted minimum standards in all visited detention centers. It is well documented that overcrowding increases the risk for communicable diseases spread, such as tuberculosis, diarrhea, upper respiratory infections, etc” European Center for Disease Control, 2011.

9. Mental health projects in Evros and Rodopi immigration detention centers (Aug. 2009-Apr. 2010) 305 patients seen in 381 individual consultations. 79 group sessions and 258 play therapy sessions. Patients: 89% male of whom 12% minors, 11% female Main countries of origin: Afghanistan, Iran, Iraq Pakistan, Somalia, Palestine, Baglandesh.

10. Impact of detention on mental health 39% of patients presented symptoms of anxiety such as constant worry, fear, panic, restlessness. 31% of patients presented symptoms of depression, such as sadness, loss of interest, hopelessness, and thoughts of death. 17.3% of patients sought psychological support due to the previous experience of traumatic events -PTSD was diagnosed in 9.5% of all patients. Detention exacerbated existing symptoms, hindered the healing process and contributed to psychological distress. 3.2% of patients had attempted suicide or self-harm during the period of their detention.

11. Impact of detention on mental health • For the majority of MSF patientsdetention was the single most important cause of stress and frustration. • Many expected some kind of humanitarian assistance and protection on arrival in Europe. As a result, detention and the feeling of being treated as criminals was experienced as particularly cruel and unjust. • Difficult living conditions, overcrowding, constant noise, lack of activities, dependence on other people’s decisions, the length and uncertainty of the period of detention and the ever present threat of forced return all contributed to feelings of defeat and hopelessness.

12. “I have never been in detention before. I feel very insecure and frightened” “I am constantly crying. I feel very worried about how long I will have to stay here. Being in detention makes me feel desperate.”

13. M.S.S. v. Belgium and Greece “a similar situation to varying degrees of gravity [is described]: overcrowding, dirt, lack of space, lack of ventilation, little or no possibility of taking a walk, no place to relax, insufficient mattresses, dirty mattresses, no free access to toilets, inadequate sanitary facilities, no privacy, limited access to care”. European Court for Human Rights, 2011

14. Recent improvements • MoH medical teams present in DCs and BPS (but not full capacity and with interruptions). • Presence (but very limited) of other NGOs (legal aid, support to unaccompanied minors). • Minor improvements in some facilities terms of infrastructure. • New legislation since 2011 provisioning the set up of a First Reception Agency and a reformed Asylum Agency.

15. Ongoing deficiencies • Inappropriate facilities (overcrowding, very poor sanitary conditions). • Gaps/interruptions in services provision (eg. medical services). • Lack of appropriate services for vulnerable groups (eg. torture victims). • Understaffing and lack of specialized personnel, such as interpreters. • Lack of protocols and procedures for the management of the facilities and the screening of new arrivals (incl. medical screening) - No systematic monitoring.

16. Ongoing deficiencies • Limited access to health care. In accordance to Greek legislations irregular migrants are only entitled to access the NHS in cases of life-threatening emergencies and need to cover incurred costs. • No follow up of cases once they are released from detention. • Very limited reception capacity for vulnerable cases (only 900 beds available in shelters for the accommodation of asylum seekers, vulnerable persons, unaccompanied minors).

17. Current MSF activities • Evros Poros registration center (since March 2012): Medical care to newly arriving migrants (triage, first aid). Filakio and Venna detention centers and border police stations: humanitarian assistance (eg. personal hygiene items) to migrants/asylum seekers in detention. • Lesvos Island: Medical and humanitarian assistance at arrival and in police stations.

18. Ioanna Kotsioni, Migration Referent,Médecins Sans Frontières, Athens ioanna.kotsioni@athens.msf.org