Medical Volunteering in Moria Refugee Camp
By Flora Burns and Rose Brennan, December 2020
In September 2020, devastating fires at a refugee camp on the Greek Island of Lesvos were reported in the news. This once again brought to the forefront of people’s minds, the desperate situation of many people fleeing their native countries and seeking asylum abroad. In this article, we provide a firsthand account of our experiences volunteering as doctors at this very same camp earlier in the year. We hope that it provides the reader with a useful insight into current conditions in these camps, and perhaps even provides inspiration for action.=
Mória Refugee Camp, on the Greek Island of Lesvos, was built in 2015 to accommodate 2,200 of the growing number of refugees escaping conflict and poverty across the Middle East and Africa. There are currently between 12,000 [1] to 20,000 [2] people living there. Owing to the camp’s overwhelming growth many inhabitants have been forced to spill out into the surrounding olive groves; building makeshift homes out of whatever they can find. This is an area known as ‘Mória Jungle’ [5]. Once named ‘the worst refugee camp on earth’ by the Field Coordinator of Médecins Sans Frontières (Doctors without Borders), many of those living there have waited for over a year for interviews to further their asylum process. Of the asylum seekers arriving in the Aegean Islands, 46% are from Afghanistan, 18% from Syria and the remainder from countries including the Democratic Republic of Congo, Somalia, Iraq and Iran [3].
In 2017 the risk of tension between communities living in the camp was rated as ‘red’ by the United Nations Refugee Agency. A number of other factors at the camp were also assigned this status including the nutritional value of food available, access to cooking equipment, and participation of school age children in formal education [3]. It is estimated that between 6,000 to 7000 camp inhabitants are children under the age of 18 [2].
We travelled to Lesvos in the summer of 2020, to volunteer as doctors with Medical Volunteers International (MVI). MVI is a non-governmental organization that has been providing medical care to displaced people in Lesvos, Thessaloniki and Athens since 2016 [4].
After arriving in Lesvos, we were required to follow a strict two-week isolation to minimize our risk of spreading Covid-19 in the camp. Covid-19 has had devastating effects on what is already a tough life for those living in the camp. However, the Greek government’s strategy to reduce transmission between the camp and the local population of Lesvos has included introducing strict lockdowns in the Camp which has exacerbated tensions.
Neither of us knew what to expect when we eventually started work. On our first day in Mória, as we entered the barbed wire enclosure under the watchful eyes of the Greek armed police, we both sensed an overwhelming feeling of tension and desperation.
The camp’s medical ‘centre’ consisted of a few isoboxes (large storage containers) with 2-3 clinic rooms in each, separated by curtains, and a small pharmacy which relied on donations from NGOs and local Greek pharmacies. In addition to this, there was a separate triage area used to screen anyone with respiratory symptoms of Covid-19. Using WHO criteria, those we identified as medium or high risk would be sent for further tests or isolation and contact tracing.
To prepare us for work at the camp, we spoke to friends and colleagues who had worked in humanitarian settings. The overriding advice we received was to identify our personal reasons for going and keep them in mind day-to-day. The importance of this became evident as our time in Mória progressed. As we talked to refugees and learned about their individual horrific stories, we found ourselves becoming despondent, saddened and powerless considering the scale of the crisis in Europe and beyond.
Upon reflection, it would be fair to say some of our incentive for volunteering was curiosity. Our work in emergency medicine in the UK often sees us treating patients who were once asylum seekers and are now living and receiving healthcare in a very unfamiliar system. It is often difficult to empathize with what they have been through before arriving in the UK. Volunteering in Mória provided a good opportunity to gain an insight into their world, as well as get some firsthand humanitarian experience.
In reality, what we learned in Mória went far beyond our expectations. Of course, we gained experience and knowledge around acute medicine in crisis settings, some of which is outlined below, but perhaps more importantly, we came away with an understanding of the human side to this ongoing tragedy. We hope that our accounts of specific cases will provide you with a true insight into the impossible and complex mess of challenges being faced by people living in Mória, as well as those attempting to work there.
Common conditions in Mória
- Gastrointestinal – reflux, constipation, gastroenteritis, IBS, intestinal worms
- ENT – otitis externa and media, traumatic bilateral ear drum perforations
- Women’s health – thrush, weak pelvic floor, antenatal care
- Dermatological – bacterial and fungal skin infections, scabies
- Respiratory – ‘Mória flu – chronic cough due to open fire smoke and dust’, suspected tuberculosis
- Psychological – insomnia, panic attacks, PTSD, memory loss, low mood, drug and alcohol use
- MSK – back pain, injuries from torture
- Other – dental caries, visual impairment, poor nutrition, weight loss
The above list is by no means exhaustive but lists some of the more common problems we saw. Something we quickly realised is many of the medical complaints were secondary to or exacerbated by living conditions and mental health, e.g., gastritis caused by poor diet but exacerbated by stress.
Thought-provoking cases from Mória
Rose: ‘One patient that really summed up the challenges of Mória for me was a woman from Afghanistan in her 40s who presented with the quite common heart sink list of problems including gastritis, back ache and difficulty sleeping. Her main problem was pain in her joints. She had been seen several times before and advised she would have to wait several months until blood tests were available for potential rheumatoid arthritis. When she saw me blood tests were still not available and she was on all the simple analgesia we had to offer as well as a trial of steroids. When I explained there was no more I could currently do she became very upset saying “you’re not helping me here at all, I wish I had never left my country, Mória is much worse”. At this point I felt so helpless, I was doing as much as I could, but she was right, I wasn’t helping, it did not feel fair at all.’
‘Another case that really stuck with me was that of a young woman from the Democratic Republic of Congo who was here on her own, which was unusual for a woman. She had come with abdominal pain, something she had had for the past year and had been investigated with an ultrasound but nothing was found. On questioning her further she opened up about being horribly abused by her ex-partner, to the extent he had caused a traumatic miscarriage which was subsequently delivered by caesarian section. The pain had been ongoing since then. Through listening to her story and exploring the reasons behind her symptoms, I was able to refer her on to the domestic and sexual violence support available in the camp’
Flora: ‘The most difficult case I was involved with was a prepubescent boy from Afghanistan who presented with genital ulcers. He was accompanied by his concerned father, the young boy was tearful and quiet. With the invaluable help of a translator’s sensitive questions, we ascertained that the family were living in an old bus in ‘Mória Jungle’ along with two other large families. We tried our hardest to get the young boy to open up about why he was tearful and if anyone had hurt him in any way. We asked the father to leave the room for a bit and the boy became even more tearful. He said some other boys had been throwing stones at him and chasing him but denied anyone touching him in a way they shouldn’t.
In the UK, a case like this would appropriately trigger red flags to social services to ensure the child was not a victim of sexual abuse. Genital ulcers can be a symptom of other acute illnesses in children however sexually transmitted infections such as herpes simplex virus should be investigated. I was struck with the heartbreaking realisation that the best I could do for this boy, alongside treating the ulcers with the antiviral medication that the clinic thankfully had, was give him and his dad the time and space to talk about their social situation and try and create a ‘safeguarding plan’ there and then. The anxious father listened and agreed to be more watchful of him. They then disappeared back into Mória. This was one of my last days working in the clinic so I handed the patient over to another volunteer who was able to follow him up.’
Challenges of working as a humanitarian doctor
Working in a refugee camp presented several challenges that we had not experienced working in UK emergency departments. A key difference was working with translators. We had to modify the way we spoke to allow the translators to understand. In addition, sometimes, despite the patient talking at length, the translator would only provide a few translated words – things definitely got lost in translation! Culturally, we faced challenges when the combination of female patient and male translator arose; neither party would be comfortable discussing intimate problems. On top of this, the majority of the translators were asylum seekers themselves and had been through similar situations to the patients. It was important to be mindful of the underlying factors that may affect the translator and try to avoid potentially burdening them further. Between clinics we had the opportunity to chat with the translators and learn about their stories as well as how they had ended up in Mória.
Access to investigations and secondary care was almost non-existent. There was a several month wait for any blood tests unless it was an emergency (each case would be assessed by the sole Greek doctor in the clinic). The same applied for secondary care referrals, this was again on an emergency-only basis. In terms of mental health support there were only two psychologists, so subsequently only the most severe cases could be seen. This difficult situation was exacerbated still further as, while we were there, much of the community support was unavailable due to Covid-19.
On a more personal note, due to the heartbreaking and desperate situations that we witnessed every day, turning off at the end of a shift and not becoming too emotionally invested was difficult. Working under camp conditions but living in NGO accommodation amongst local Greeks living their everyday lives was a strange juxtaposition. We had to fight an urge to try and force change. We were only there for a short time, and although the system was flawed, we were never going to fully understand it and bring about long-term changes. We had to appreciate what we were able to do both there, and back in the UK. Coming home and going back to work in the comparatively well-resourced NHS, we have realized the importance of perspective when it comes to how people experience ill health and hardship.
How can you get involved?
It was by no means just doctors that were needed camp Mória. Integral roles at the camp included allied health professionals such as paramedics, nurses, psychologist, physios, as well as people with an aptitude for people management skills and logistics. The wider group of NGO workers include teachers, plumbers and lawyers. Working in a refugee camp is challenging and not always the most rewarding experience, but overall it is something we would definitely both do again. Even the relatively small changes you make can be significant for people at a very difficult time in their lives.
Top tips
- There is no pressure to do things and remember your own limitations. Never agree to work in a situation where you feel unsafe or you are working outside of your competence. You will be working alongside doctors and nurses from many different countries with various backgrounds and levels of experience. The ‘professional hierarchy’ we are used to in our native healthcare systems no longer exists. We were lucky enough to have a consultant in the UK who was happy to answer clinical questions and support us. Don’t be afraid to question practices that you are not familiar or happy with.
- Write a risk assessment. Consider your personal and health insurance including any vaccinations and professional indemnity.
- Prior experience – having some experience in primary care or emergency medicine is invaluable. To work with organisations such as Médecins Sans Frontières, the Diploma of Tropical Medicine and Hygiene is an absolute requirement however it is also a very useful qualification to have in many humanitarian settings.
- Be self-sufficient – find below a ‘kit list’ we found useful
- Don’t be naïve. Do as much background research as you can about the organisation you are working with, the political situation in the country, the outlook for the asylum seekers, cultural backgrounds of translators and patients. Try and remain sensitive to the variety of cultures and religions through your behaviour and dress.
- Focus on the small changes you might be making on a case-by-case basis. Strive to be patient. Sometimes the most useful thing you can do for someone is just sitting and listening.
- Many of the asylum seekers come from countries where they had very good levels of health care. They have high expectations – managing these can be incredibly challenging and frustrating at times.
- The translators are invaluable! We were constantly reminded how vital it is to look out for the translator’s welfare and ensure they remain neutral within a consultation.
- Remember your personal reason for going. Keeping in mind your specific aims is useful for maintaining your own morale.
- Coming home – debrief and spread the word through reflecting and talking about your experiences.
Kit List
All medical kit below was available in the clinic, except the stethoscopes. However, it may be of questionable quality or not always working.
- Pulse oximeter, temperature probe and manual blood pressure monitor
- Ophthalmoscope and otoscope
- Urine test kit, pregnancy tests and blood glucose machine
- Any medication you can bring including any over the counter medication that we take for granted in the UK including simple analgesia, diarrhea and constipation relief, multivitamins, antihistamines, cough syrups
- First aid kit and suture kit
- Personal protective equipment – the clinic was well equipped with PPE however it was nice to not use up their valuable supply
- Food and drink – make sure you are self-sufficient you never know when you might be able to get a break
- A positive mindset!
References
- Melissa Godin. Blaze That Destroyed Greece’s Moria Refugee Camp Symbolizes Breakdown in E.U. Over Future of Migrants. Time [Newspaper on the Internet]. 2020 Sept 10 [cited 2020 Dec 01].
Available from: www.time.com
- Aegean Boat Report. [Weekly statistics update on the internet]. Dec 2020, [cited 2020 Dec 09]
Available from: www.aegeanboatreport.com
- The United Nations High Commissioner for Refugees. Aegean Islands Weekly Snapshot. [Internet]. 23-29 November 2020 [cited 2020 November 03].
Available from: www.data2.unhcr.org
- Medical Volunteers International What we do? NGO website [cited 2020 Dec 09] Available from: www.medical-volunteers.org
- Bill Frellick. Greece: Refugee Hotspots, Unsafe, Unsanitary. Human Rights Watch. [Internet] 2019 May [cited 2020 Dec 09]
Available from: www.hrw.org
In September 2020, devastating fires at a refugee camp on the Greek Island of Lesvos were reported in the news. This once again brought to the forefront of people’s minds, the desperate situation of many people fleeing their native countries and seeking asylum abroad. In this article, we provide a firsthand account of our experiences volunteering as doctors at this very same camp earlier in the year. We hope that it provides the reader with a useful insight into current conditions in these camps, and perhaps even provides inspiration for action.
Mória Refugee Camp, on the Greek Island of Lesvos, was built in 2015 to accommodate 2,200 of the growing number of refugees escaping conflict and poverty across the Middle East and Africa. There are currently between 12,000 [1] to 20,000 [2] people living there. Owing to the camp’s overwhelming growth many inhabitants have been forced to spill out into the surrounding olive groves; building makeshift homes out of whatever they can find. This is an area known as ‘Mória Jungle’ [5]. Once named ‘the worst refugee camp on earth’ by the Field Coordinator of Médecins Sans Frontières (Doctors without Borders), many of those living there have waited for over a year for interviews to further their asylum process. Of the asylum seekers arriving in the Aegean Islands, 46% are from Afghanistan, 18% from Syria and the remainder from countries including the Democratic Republic of Congo, Somalia, Iraq and Iran [3].
In 2017 the risk of tension between communities living in the camp was rated as ‘red’ by the United Nations Refugee Agency. A number of other factors at the camp were also assigned this status including the nutritional value of food available, access to cooking equipment, and participation of school age children in formal education [3]. It is estimated that between 6,000 to 7000 camp inhabitants are children under the age of 18 [2].
We travelled to Lesvos in the summer of 2020, to volunteer as doctors with Medical Volunteers International (MVI). MVI is a non-governmental organization that has been providing medical care to displaced people in Lesvos, Thessaloniki and Athens since 2016 [4].
After arriving in Lesvos, we were required to follow a strict two-week isolation to minimize our risk of spreading Covid-19 in the camp. Covid-19 has had devastating effects on what is already a tough life for those living in the camp. However, the Greek government’s strategy to reduce transmission between the camp and the local population of Lesvos has included introducing strict lockdowns in the Camp which has exacerbated tensions.
Neither of us knew what to expect when we eventually started work. On our first day in Mória, as we entered the barbed wire enclosure under the watchful eyes of the Greek armed police, we both sensed an overwhelming feeling of tension and desperation.
The camp’s medical ‘centre’ consisted of a few isoboxes (large storage containers) with 2-3 clinic rooms in each, separated by curtains, and a small pharmacy which relied on donations from NGOs and local Greek pharmacies. In addition to this, there was a separate triage area used to screen anyone with respiratory symptoms of Covid-19. Using WHO criteria, those we identified as medium or high risk would be sent for further tests or isolation and contact tracing.
To prepare us for work at the camp, we spoke to friends and colleagues who had worked in humanitarian settings. The overriding advice we received was to identify our personal reasons for going and keep them in mind day-to-day. The importance of this became evident as our time in Mória progressed. As we talked to refugees and learned about their individual horrific stories, we found ourselves becoming despondent, saddened and powerless considering the scale of the crisis in Europe and beyond.
Upon reflection, it would be fair to say some of our incentive for volunteering was curiosity. Our work in emergency medicine in the UK often sees us treating patients who were once asylum seekers and are now living and receiving healthcare in a very unfamiliar system. It is often difficult to empathize with what they have been through before arriving in the UK. Volunteering in Mória provided a good opportunity to gain an insight into their world, as well as get some firsthand humanitarian experience.
In reality, what we learned in Mória went far beyond our expectations. Of course, we gained experience and knowledge around acute medicine in crisis settings, some of which is outlined below, but perhaps more importantly, we came away with an understanding of the human side to this ongoing tragedy. We hope that our accounts of specific cases will provide you with a true insight into the impossible and complex mess of challenges being faced by people living in Mória, as well as those attempting to work there.
Common conditions in Mória
- Gastrointestinal – reflux, constipation, gastroenteritis, IBS, intestinal worms
- ENT – otitis externa and media, traumatic bilateral ear drum perforations
- Women’s health – thrush, weak pelvic floor, antenatal care
- Dermatological – bacterial and fungal skin infections, scabies
- Respiratory – ‘Mória flu – chronic cough due to open fire smoke and dust’, suspected tuberculosis
- Psychological – insomnia, panic attacks, PTSD, memory loss, low mood, drug and alcohol use
- MSK – back pain, injuries from torture
- Other – dental caries, visual impairment, poor nutrition, weight loss
The above list is by no means exhaustive but lists some of the more common problems we saw. Something we quickly realised is many of the medical complaints were secondary to or exacerbated by living conditions and mental health, e.g., gastritis caused by poor diet but exacerbated by stress.
Thought-provoking cases from Mória
Rose: ‘One patient that really summed up the challenges of Mória for me was a woman from Afghanistan in her 40s who presented with the quite common heart sink list of problems including gastritis, backache and difficulty sleeping. Her main problem was pain in her joints. She had been seen several times before and advised she would have to wait several months until blood tests were available for potential rheumatoid arthritis. When she saw me blood tests were still not available and she was on all the simple analgesia we had to offer as well as a trial of steroids. When I explained there was no more I could currently do she became very upset saying “you’re not helping me here at all, I wish I had never left my country, Mória is much worse”. At this point I felt so helpless, I was doing as much as I could, but she was right, I wasn’t helping, it did not feel fair at all.’
‘Another case that really stuck with me was that of a young woman from the Democratic Republic of Congo who was here on her own, which was unusual for a woman. She had come with abdominal pain, something she had had for the past year and had been investigated with an ultrasound but nothing was found. On questioning her further she opened up about being horribly abused by her ex-partner, to the extent he had caused a traumatic miscarriage which was subsequently delivered by caesarian section. The pain had been ongoing since then. Through listening to her story and exploring the reasons behind her symptoms, I was able to refer her on to the domestic and sexual violence support available in the camp’
Flora: ‘The most difficult case I was involved with was a prepubescent boy from Afghanistan who presented with genital ulcers. He was accompanied by his concerned father, the young boy was tearful and quiet. With the invaluable help of a translator’s sensitive questions, we ascertained that the family were living in an old bus in ‘Mória Jungle’ along with two other large families. We tried our hardest to get the young boy to open up about why he was tearful and if anyone had hurt him in any way. We asked the father to leave the room for a bit and the boy became even more tearful. He said some other boys had been throwing stones at him and chasing him but denied anyone touching him in a way they shouldn’t.
In the UK, a case like this would appropriately trigger red flags to social services to ensure the child was not a victim of sexual abuse. Genital ulcers can be a symptom of other acute illnesses in children however sexually transmitted infections such as herpes simplex virus should be investigated. I was struck with the heartbreaking realisation that the best I could do for this boy, alongside treating the ulcers with the antiviral medication that the clinic thankfully had, was give him and his dad the time and space to talk about their social situation and try and create a ‘safeguarding plan’ there and then. The anxious father listened and agreed to be more watchful of him. They then disappeared back into Mória. This was one of my last days working in the clinic so I handed the patient over to another volunteer who was able to follow him up.’
Challenges of working as a humanitarian doctor
Working in a refugee camp presented several challenges that we had not experienced working in UK emergency departments. A key difference was working with translators. We had to modify the way we spoke to allow the translators to understand. In addition, sometimes, despite the patient talking at length, the translator would only provide a few translated words – things definitely got lost in translation! Culturally, we faced challenges when the combination of female patient and male translator arose; neither party would be comfortable discussing intimate problems. On top of this, the majority of the translators were asylum seekers themselves and had been through similar situations to the patients. It was important to be mindful of the underlying factors that may affect the translator and try to avoid potentially burdening them further. Between clinics we had the opportunity to chat with the translators and learn about their stories as well as how they had ended up in Mória.
Access to investigations and secondary care was almost non-existent. There was a several month wait for any blood tests unless it was an emergency (each case would be assessed by the sole Greek doctor in the clinic). The same applied for secondary care referrals, this was again on an emergency-only basis. In terms of mental health support there were only two psychologists, so subsequently only the most severe cases could be seen. This difficult situation was exacerbated still further as, while we were there, much of the community support was unavailable due to Covid-19.
On a more personal note, due to the heartbreaking and desperate situations that we witnessed every day, turning off at the end of a shift and not becoming too emotionally invested was difficult. Working under camp conditions but living in NGO accommodation amongst local Greeks living their everyday lives was a strange juxtaposition. We had to fight an urge to try and force change. We were only there for a short time, and although the system was flawed, we were never going to fully understand it and bring about long-term changes. We had to appreciate what we were able to do both there, and back in the UK. Coming home and going back to work in the comparatively well-resourced NHS, we have realized the importance of perspective when it comes to how people experience ill health and hardship.
How can you get involved?
It was by no means just doctors that were needed camp Mória. Integral roles at the camp included allied health professionals such as paramedics, nurses, psychologist, physios, as well as people with an aptitude for people management skills and logistics. The wider group of NGO workers include teachers, plumbers and lawyers. Working in a refugee camp is challenging and not always the most rewarding experience, but overall it is something we would definitely both do again. Even the relatively small changes you make can be significant for people at a very difficult time in their lives.
Top tips
- There is no pressure to do things and remember your own limitations. Never agree to work in a situation where you feel unsafe or you are working outside of your competence. You will be working alongside doctors and nurses from many different countries with various backgrounds and levels of experience. The ‘professional hierarchy’ we are used to in our native healthcare systems no longer exists. We were lucky enough to have a consultant in the UK who was happy to answer clinical questions and support us. Don’t be afraid to question practices that you are not familiar or happy with.
- Write a risk assessment. Consider your personal and health insurance including any vaccinations and professional indemnity.
- Prior experience – having some experience in primary care or emergency medicine is invaluable. To work with organisations such as Médecins Sans Frontières, the Diploma of Tropical Medicine and Hygiene is an absolute requirement however it is also a very useful qualification to have in many humanitarian settings.
- Be self-sufficient – find below a ‘kit list’ we found useful
- Don’t be naïve. Do as much background research as you can about the organisation you are working with, the political situation in the country, the outlook for the asylum seekers, cultural backgrounds of translators and patients. Try and remain sensitive to the variety of cultures and religions through your behaviour and dress.
- Focus on the small changes you might be making on a case-by-case basis. Strive to be patient. Sometimes the most useful thing you can do for someone is just sitting and listening.
- Many of the asylum seekers come from countries where they had very good levels of health care. They have high expectations – managing these can be incredibly challenging and frustrating at times.
- The translators are invaluable! We were constantly reminded how vital it is to look out for the translator’s welfare and ensure they remain neutral within a consultation.
- Remember your personal reason for going. Keeping in mind your specific aims is useful for maintaining your own morale.
- Coming home – debrief and spread the word through reflecting and talking about your experiences.
Kit List
All medical kit below was available in the clinic, except the stethoscopes. However, it may be of questionable quality or not always working.
- Pulse oximeter, temperature probe and manual blood pressure monitor
- Ophthalmoscope and otoscope
- Urine test kit, pregnancy tests and blood glucose machine
- Any medication you can bring including any over the counter medication that we take for granted in the UK including simple analgesia, diarrhea and constipation relief, multivitamins, antihistamines, cough syrups
- First aid kit and suture kit
- Personal protective equipment – the clinic was well equipped with PPE however it was nice to not use up their valuable supply
- Food and drink – make sure you are self-sufficient you never know when you might be able to get a break
- A positive mindset!
References
- Melissa Godin. Blaze That Destroyed Greece’s Moria Refugee Camp Symbolizes Breakdown in E.U. Over Future of Migrants. Time [Newspaper on the Internet]. 2020 Sept 10 [cited 2020 Dec 01].
Available from: www.time.com
- Aegean Boat Report. [Weekly statistics update on the internet]. Dec 2020, [cited 2020 Dec 09]
Available from: www.aegeanboatreport.com
- The United Nations High Commissioner for Refugees. Aegean Islands Weekly Snapshot. [Internet]. 23-29 November 2020 [cited 2020 November 03].
Available from: www.data2.unhcr.org
- Medical Volunteers International What we do? NGO website [cited 2020 Dec 09] Available from: www.medical-volunteers.org
- Bill Frellick. Greece: Refugee Hotspots, Unsafe, Unsanitary. Human Rights Watch. [Internet] 2019 May [cited 2020 Dec 09]
Available from: www.hrw.org
Being a firefighter in Australia a lot of people have asked me for my opinion on the current bushfire crisis – so let’s talk about the fires.
