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Acute health problems, public health measures and administration procedures during arrival/transit phase

Apostolos Veizis,M.DDirector of the Medical Support Unit

apostolos.veizis@athens.msf.org

Who is Médecins Sans Frontières(MSF)?MSF was founded by a group of doctors and journalists

in Paris on 20 December 1971 following the Biafran war in

Nigeria.

MSF was founded by a group of doctors and journalists

in Paris on 20 December 1971 following the Biafran war in

Nigeria.

Today, MSF is a worldwide movement of more than 40.000 health professionals, logistical and administrative staff save lives and alleviate suffering in some 70 countries worldwide.

Today, MSF is a worldwide movement of more than 40.000 health professionals, logistical and administrative staff save lives and alleviate suffering in some 70 countries worldwide.

Impartiality

IndependenceNeutrality

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Health is a state of complete physical, mental and social well‐being and not merely the absence of disease or infirmity

The correct bibliographic citation for the definition is:

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19‐22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

The Definition has not been amended since 1948.

WHO definition of Health

Travel medicine or emporiatrics is the branch of medicine that deals with the prevention and management of health problems of international travelers

MSF interventions: Criteria forIntervention - Why

Focus not on the phenomenon of migration but on the impactincreased restrictions and controls on the health and dignity of the persons affected

Within that group, focus on the most vulnerable among the migrants, on their unmet medical and humanitarian needs

Target - Who

Factors to consider/criteria

Cumulative vulnerability

Unmet medical and humanitarian needs

Poor or absent capacity or lack of political will

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MSF’s commitment to assist people on the move stems from their increasing vulnerability at different moments and stages of the migration process. 

This is considered by MSF a crisis where life, health and human dignity are being put at risk.

Life, health and human dignityat risk

MSF activities in brief… Medical screening at arrival

Primary Health care and health promotion

Referral/accompaniment to secondary health facilities

SGBV care

Visit of detention and reception centers

Mental health care and psychosocial activities

Detection of vulnerable groups

NFIs distribution at arrival and during transit

Watsan

Individual protection cases referral

Medical certification/Rehabilitation of VoT

Chronic medical conditions and continuity of care

SAR

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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.

Impact of detention on physical health

Upper respiratory tract infection (24,7%), musculoskeletal condition(13,7%),gastointestinal disorders(14,7%), skin infections (8,5%), dental problem (7,9%).

In total 63% of total diagnoses were 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.

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 previousexperience 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.

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“Migrants and asylum seekers in detention suffer from medical problems caused or aggravated by the substandard conditions, the length of detention, and the lack of consistent or adequate medical assistance. MSF’s experiencedemonstrates that detention is a cause of suffering and is directly linked to themajority of the health problems for which detained migrants require medical attention“

New areas and locations:

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Vulnerable groups 

• Pregnant women

• Children <5yrs 

• Unaccompanied minors

• Single parents with minor children

• Elderly (>65yrs)• Disabled• Chronic physical or mental health illness

@MSF/Vicky Marcolefa

@MSF/Guillaume Binet

@MSF/Alex Yallop

@MSF/Anna Surinyach

PHC consultations, Greece (N=43,619) & Serbia (N=38,249), 2015

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

nb of consultations

Greece Serbia

Socio-demographics: Primary health care

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Socio-demographics: Mental health Health status by country (N=81,868)

• 93%: symptom onset during the migration trip

Chronic diseases & referrals (N=81,868)

Chronic diseases (4564; 6%)• Cardiovascular (26%)• Diabetes (25%)• Chronic lung disease (15%)• Epilepsy (3%)

→ 11% (77/681) referral refused

• Gynaeco‐obstetric (n=21)

• Respiratory (n=12)

Referrals (681; 1%)

• Trauma (20%)

• Respiratory (14%)  

• Gyneco‐obstetric (12%)    

@MSF/Achilleas Zavallis

Traumatic life events before & during the journey (N=1064)

Self-reported traumatic life events Self-reported intentional violence

7%

12%

10%

7%

0% 5% 10% 15% 20% 25%

Sexual violence

Ill‐treatment

Physical violence

State authorities Community/smugglers

@MSF/Juan Carlos Tomasi

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Our mental health activityActivities:- Mostly group sessions. Added value: groupcohesion; promote community/cultural resources;address bigger numbers of beneficiaries- Special sessions engaging with children, oftenattracting adults too- Identification of vulnerable cases and of localreferral networks- In individual sessions, the single shot method isused.

Main challenges:- Population in transit: close to impossible tohave any type of follow-up ; difficult to createinterest in our support and sensitize people towhat it is we do- Marked separation between the variouscommunities- Privacy with our beneficiaries

Mental health symptoms (78%; 830/1064)

The kit

Arrivals, 3667

0

50000

100000

150000

200000

250000

Closure of Balkans route

EU – TK Deal

First restriction at Balkans borders

FLOW OF ARRIVALS FROM TURKEY TO GREECE

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People with specific needs 

Victims of violence or other forms of ill‐treatment

People with psychiatric disorders 

People with physical disabilities

Pregnant women

Children

Dental Care

in late 2016 and early 2017 95% of the people surveyed had fled from war. 

80% of our new mental health patients treated in July and August 2017 on Lesvos reported experiencing), just over a quarter reported experiencing torture and 19% reported experiencing sexual violence 

This violence was experienced in people’s country of origin, in transit and in Greece 

Total participants

Experienced violence

(except in country of

origin)

Arrived before 20th March

Arrived after 20th March

Arrived before 20th March and

experienced violence

Arrived after 20th March and

experienced violence

NB % NB % NB % NB

% from those who arrived before 20th

March

NB

% from those who arrived

after 20th March

Ritsona 310 92 29.7% 228 73.5% 82 26.5% 58 25.4% 34 41.5%

Malakasa 224 66 29.5% 159 71.0% 65 29.0% 50 31.4% 16 24.6%

Katsikas 140 48 34.3% 133 95.0% 7 5.0% 46 34.6% 2 28.6%

Ioannina hotel 122 31 25.4% 119 97.5% 3 2.5% 30 25.2% 1 33.3%

Samos 240 144 60.0% 4 1.7% 236 98.3% 2 50.0% 142 60.2%Soho hotel

(Athens) 141 45 31.9% 116 82.3% 25 17.7% 35 30.2% 10 40.0%

TOTAL 1177 426 36.2% 759 64.5% 418 35.5% 221 29.1% 205 49.0%

SUFFERING FROM STATE BASED VIOLENCE…

Dire Mental Health Situation

The living conditions in the camp

The lack of legal information and assistance

The uncertainty about the future

The feeling of insecurity

The isolation and discrimination

The destruction of the family entity

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0%

5%

10%

15%

20%

25%

30%

35%

40%

January February March April May June July August September October November December

Proportion of most common reasons for MH consultations

Depression PTSD Anxiety

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

Q1 Q2 Q3 Q4

Symptoms of anxiety

Symptoms of depression

Symptoms of PTSD

Symptoms of adjustment/acute reactions

Other

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The scale of people's mental health needs is overwhelming: on Lesvos, between early July and 21 August 2017 – which represents a 50% increase compared to the period April‐June 2017

In addition to that, an average of six to seven people have presented to our clinic each week since July, requiring immediate and urgent care linked to attempted suicide, self‐harm, psychosis and other emergencies 

Morbidities by MDs by quarter 2017

80.8%

18.0%10.3% 8.1%

4.0%

25.0%

9.6%7.2%

3.6%

6.3%

3.0%

4.8%

5.7%

33.6%54.0%

5.6%

18.4%

21.3%

17.4%13.2%

14.0%

7.2%16.1%

5.0% 3.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1 Q2 Q3 Q4

Other (not NCD) total

Gastro‐intestinal symptoms

musculoskeletal pain

mental health symptoms

headache

Acute Infections

Diagnosed NCDs

Total consultations in number

Proportion % under 5 year

W48 124 52%W49 274 54%W50 215 59%W 51 188 48%

56

135146

488

0

5376

190

0

100

200

300

400

500

600

Q1 Q2 Q3 Q4

Demand for MSF MH Services

New Referrals TO MSF

Screens of urgent cases

Non communicable diseases

Increase of patients suffering from chronical diseases 

Adapt our HP strategy according to level of education of the migrants according to counties of origins.

Limited access to protection and care for very vulnerable people

Challenging access to healthcare 

A lack of referral pathway to have access to protection and care

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There is a need for capacity building of professionals to develop intercultural understanding and knowledge of the situation and needs of migrants in the country, to avoid misunderstanding of symptoms and diagnosis difficulties, that can ultimately lead to an over-pathologization of what are often normal reactions to abnormal circumstances.

There are great difficulties in finding accommodation/shelters for severe cases or for patients after hospitalization.

MSF 2017-2018

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Human dignity is inviolable. It must be respected and 

protected