Abstract
After 2 years of GP training, I began a Global Health Fellowship (GHF), having previously intercalated in International Health and completed various projects abroad. My first placement was volunteering with a medical Non-Governmental Organisation (NGO) on the island of Lesvos, Greece. There I worked as a primary care doctor in Europe’s largest refugee camp, known as Moria Reception and Identification Centre (Moria RIC). On 8 September 2020, a catastrophic fire broke out in the camp, destroying the majority of the tents and structures and displacing around 12 000 asylum seekers onto the streets of Lesvos. Over the following weeks, Greek authorities built a new, temporary camp and NGOs worked together to meet the basic needs of the displaced population in addition to managing COVID-19 risks, operating in an area exposed to extreme winds and responding to an earthquake in November 2020. My experience, while both eye-opening and sobering, provided an invaluable opportunity for learning and professional development.
Background
Lesvos is the epicentre of the refugee crisis in the Aegean Islands, which collectively received over 60,000 asylum seekers by boat in 2019 (Aegean Boat Report, 2019). In early 2020, Lesvos’ asylum seeker population peaked at over 20 000 people (Aegean Boat Report, 2020) with the vast majority residing in Moria RIC.
The population of the Moria RIC has generally fled persecution to themselves or their families, often originating from conflict-torn areas. They have undertaken long journeys from countries including Afghanistan, Syria and the Democratic Republic of Congo and, via Turkey, face a host of dangers along the way, including risk of arrest and deportation, extortion, discrimination and, in recent months, “push backs” where coastal authorities intercept boats and forcibly return them to Turkish waters. Upon arrival in Moria RIC, asylum seekers face months of waiting in deplorable conditions; navigating an asylum system which they are given very little explanation about, including basic information on their rights.
Moria RIC was famously overcrowded for years, resulting in a huge overflow of makeshift shelters into the surrounding countryside. Alongside a small number of Greek government doctors, basic primary and emergency medical care was predominately co-ordinated by a collective of NGOs. Many of these services were limited by COVID-19, as the local hospital accepted emergencies only. It had already been a turbulent year for the island: tensions were increasing with protests from locals and fascist groups in February 2020 coupled with international calls for change and worsening camp conditions due to overcrowding.
The September fire changed the whole situation overnight. Thousands of people were stranded on a main road close to Mytilini, Lesvos’ capital, contained by a blockade of riot police and the army. Access to patients was increasingly difficult, so our medical team was temporarily redeployed to assist with food and water distribution. During this time, many high-risk patients and unaccompanied minors were transferred to other parts of Greece while a new camp was built on a disused military firing range. Despite the transfers, thousands were forcibly relocated to the new camp, facing problems including extremely limited access to running water and shower facilities, flooding and high winds. After much uncertainty, select NGOs were permitted access to the new camp to work alongside Greek authorities to re-establish the provision of medical services (Fig. 1).
NGO doctor reviews an X-ray in the new camp clinic.
Patient caseload
The conditions in the camps, coupled with the traumatic experiences of the patients themselves, were evident in the primary care presentations. Bacterial and fungal skin infections were common in all ages, as well as bed bugs and lice. Scabies was endemic, though we weren't permitted to provide curative treatment for prolonged periods. The authorities favoured a camp-wide eradication programme, though the funding or medication required never materialised. Musculoskeletal complaints and gastritis were common, both largely related to the poor living space and food quality paired with high levels of stress.
Mental health was a powerful factor in many of the presentations. In the emergency room we regularly dealt with panic attacks, varying from hysterical hyperventilation to complete loss of function or seizures. I experienced a huge range of psychosomatic complaints, brought on, or exacerbated by, the camp setting and patients’ social context. Demand for mental health and counselling services far exceeded supply.
On entering the new camp, all asylum seekers and refugees underwent rapid COVID-19 testing. Positive cases were isolated for 2 weeks in a tented area, surrounded with barbed wire. This created tension, as some patients believed tests were fabricated to discriminate against them, or that the threat of COVID-19 was being used to restrict movement outside of the camp. However, incidence was generally low.
The complexities of the asylum process also required consideration during consultations. A patient diagnosed with selected co-morbidities could be assessed for the designation of having a ‘vulnerable status’. This could determine eligibility for transfer to the mainland. Patients warranting hospital referral were granted temporary permission to leave the camp. Many patients would ask for legal advice or letters of recommendation; an insight into the difficulties of accessing legal support. All of these factors could influence the patient agenda in consultations.
Reflections
During the placement, social history and context became crucial to successful consultations and relevant to the potential success of a management plan. Asking a family with scabies to hot wash all their clothes and bedding themselves was impractical when there were not even showers. Using interpreters frequently reinforced the need for concise and focused histories and explanations. Holistic care and lifestyle advice often became the foundation of management plans, especially where investigations and referrals were limited. Unreliable pharmacy supplies cultivated a pragmatic approach to evidence-based alternatives and second-line treatments for common conditions. I found that GPs (or trainees) were some of the better equipped medics to work in the clinic, due to the focus on consultation skills and breadth of knowledge in our training scheme.
On a personal level, I was taken out of my comfort zone and exposed to the harsh realities faced by many asylum seekers across the world. I visited new-born babies being raised in tents, saw the physical and mental effects of torture and treated patients who had suffered immense loss: one of my patients’ children drowned en route to Greece. I worked in an environment where I could not easily investigate or refer. Listening to a patient’s story and offering encouragement was often the most beneficial intervention I could give to a group that felt powerless and unheard. Via my NGO, I was able to research and privately investigate some patients with persistent complaints, facilitating diagnoses such as an adrenal tumour in a patient with Cushing’s syndrome and ureaplasma infection as a cause of persistent urethritis. I witnessed the influence of local and national politics on the operation of NGOs, regarding access to the camp, allocated space and the conditions we were permitted to manage and treat. Our team had to reflect and consider actions taken, including the political implications and inferences of working inside a new camp when international calls were being made to evacuate the island completely.
Conclusion
Working in this setting presented an opportunity to learn more about the ongoing refugee crisis and attempt to understand the challenges and stigma that asylum seekers face. My experience was that the majority of asylum seekers have left their countries seeking safety, showing remarkable resilience coping with unimaginable conditions and experiences, both before and after arriving in Europe. The work itself was incredibly rewarding and beneficial, though also frustrating and emotionally draining. I have learnt so much that will improve my practice in the UK and adapt the way I approach not just asylum seekers but other vulnerable groups in consultations. I would strongly advocate working in similar settings using routes such as the GHF programme. It is clear to me that GPs have a lot of knowledge and skills to offer in this kind of crisis, and a lot to learn.
