Covid-19 among refugees in Greece: an avoidable catastrophe

As a GP working in the UK where we are fast approaching 100,000 covid-19 cases, my thoughts turn to Greece where I volunteered with Kitrinos (a humanitarian organisation which provides primary health care to refugees in Moria camp, Lesvos) during  December 2019 – January 2020. Greece has been praised for the strict lockdown measures it enforced for civilians perhaps contributing to the fact that they currently have less than 2,000 cases recorded across the country. However, I think of the refugees – men, women and children – who live in cramped, unsanitary conditions which are unfit for human living – where self-isolation and sanitation are a luxury. Moria (the largest refugee camp on Lesbos island) shelters approximately 22,000 people in a camp designed for 3000.

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First covid-19 cases among refugees in Ritsona camp near Athens

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At the time of writing there had been no confirmed cases of covid-19 within Moria camp however twenty cases have been detected in Ritsona camp near Athens on the Greek mainland; this has led to a quarantine  for two whole camps which has led to protests. The pandemic has stopped progress of the EU’s voluntary returns scheme which was announced last month, and stalled progress on resettling 1600 unaccompanied minors in Europe.

 

Overcrowding and poor sanitation

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It takes little imagination to picture how rapidly SARS-CoV-2 could progress among refugee camps in Greece. In parts of Moria camp there is one tap for approximately 1,300 people. Tents and ad hoc shelters are squeezed haphazardly into the tightest of spots and nobody has enough room; in some cases more than one family share the same tent. There is no choice but to wait in queues, in close proximity, for hours for food, to wash clothes or to shower. Sewage and garbage disposal are inadequate. Prior to this international crisis, I heard many volunteers say that “this is a perfect storm for a pandemic.”

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Measures introduced in the UK including social distancing, self-isolation and lockdown are impractical and unenforceable where space and sanitation are at a premium. Organisations and individuals have appealed for the most vulnerable to be removed immediately from such settings however this process has been slow. Refugee populations in Greece include a significant proportion who are elderly or living with chronic disease leaving them vulnerable to severe infection with SARS-CoV-2. Younger people have lived with chronic physical and mental stress and sub-optimal nutrition which may also leave them vulnerable.

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Building frustrations

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Just prior to the covid-19 pandemic, unrest hit Lesvos island prompting the evacuation of many volunteers. A minority of locals formed mobs who, angry at the presence of tens of thousands of refugees, physically attacked volunteers who they blame for perpetuating the situation. Soon after the ‘One Happy Family’ school of peace, a vital source of hope and support, was burned down. This violence, coupled with the pandemic (included the grounding of many flights) has meant many volunteers have had to reconsider their travel to Greece; this has left only a skeleton healthcare team on the ground at a time where healthcare needs are among the highest they have been.

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What needs to happen?

 

Moria-based medical charity Kitrinos's director, Dr Siyana Mahroof-Shaffi is working with the UNHCR who will assist in implementing changes including alternative arrangements for food queues and dividing the camp into sections based upon facilities, as isolation within tents will be impossible. They have already made changes to divert possible cases away from the clinic. MSF have called for the evacuation of the refugee camps in Greece; this is particularly important for the most vulnerable where mortality could be high.

 

Covid-19 has overwhelmed high functioning health systems even in the UK due the relatively high proportion requiring hospital admission including ventilation. Identification or construction of facilities for quarantining of suspected cases is essential. Plans must be made to increase local hospital capacity to manage a surge in severe cases and to safely transport those patients to hospital. In Greece, the health system has already been challenged by the economic crisis and though refugees with police papers should have equal access to healthcare in the Greek health system, access will, in reality be challenging.

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Communication with refugees, volunteers and staff in Greece is essential; I’ve seen how in the UK, counter-productive rumours and misinformation can spread. There must be a clear, accessible and continuous channel of official communication in languages accessible to the refugees (which includes Farsi, French, Lingala and Arabic).

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In the UK, we have shifted primary care to a predominantly telemedicine model and have ceased all but essential healthcare services. In the camps, primary health care providers must immediately change their services to protect staff and patients. Telephone or distant consulting, empirical prescribing in place of thorough examinations, and health behaviour re-training are imperative. Routine healthcare may have to be reduced in the camps to the absolute essential and vulnerable patients advised not to attend clinic except in an emergency. Language barriers, unreliable electricity and the lack of secondary care capacity will be just some of the challenges.

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In practice, the challenges in providing healthcare for the 115,000 refugees who remain Greece has overwhelmed the Greek response. This current threat occurs on a background of political wrangling; the recent opening of Turkish borders following conflict on Turkey’s border with Syria caused refugees to surge towards Greece leading to chaotic and violent scenes at the borders. 

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Reflections

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I first volunteered as a doctor in Greece in 2016 (with the Syrian American Medical Society) at the height of refugee arrivals. Even then, it was predictable that conditions could deteriorate with ineffective WASH (water, sanitation and hygiene) solutions and overcrowded uninhabitable camps being the norm. I now see that in 2020, we, the international community have yet to be able to provide dignified safe healthcare and shelter for refugees who have mostly fled conflict. Approximately 36% of Greek refugees are children.

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If you’ve been to one of these camps, it’s hard to imagine that refugees will be prioritised despite the imminent threat of humanitarian disaster. Yet SARS-CoV-2 does not respect race, wealth or borders, and perhaps like the wet-markets of China, the looming outbreaks may cause Greek and other European neighbours to reconsider their tolerance of inhumane conditions which serve as incubators of virus and future transmission.  

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There is urgency now in addressing the situation for refugees in Greece – as the trajectory should cases continue in the camps is entirely predictable and catastrophic.

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