Commentary: “Leave No One Behind” and Access to Protection in the Greek Islands in the COVID‐19 Era

The ethical–legal perspective is inevitable when addressing the issue of migrants’ health. It is clear that the recognition of the protection of health as a universal right, unconditionally held by every individual without the constraints of meeting specific requirements (such as citizenship or residence permit), is the basis of policies and of any possible forms of protection at both global and local levels (Marceca, 2017). Public health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988). Activities to strengthen public health capacities and service aim to provide conditions under which people can maintain, improve their health and well‐being, or prevent the deterioration of their health. Public health focuses not only on the eradication of particular diseases but also on the entire spectrum of health and well‐being. As the Resolution of the Sixty‐First World Assembly of Health call “to promote equitable access to health promotion, disease prevention and care for migrants, subject to national laws and practice, without discrimination on the basis of gender, age, religion, nationality or race”, there would be no public health without refugee and migrant health.1.

Today, almost 40,000 humans – children, women and men – are contained in the five centres for reception and identification on the Greek islands, which have a capacity to host only 6,095 people. Most asylum seekers in the island camps are from Syria, Afghanistan, Iraq and DRC. In Lesvos, 20,000 people are living in a space designed for 2,840, and in Samos, 7,500 people are living in a place designed for 648.2. Up to the present day, we have not seen a credible emergency plan to protect and treat people living there in case of an outbreak. Evidence suggests that it would be impossible to contain an outbreak in the camp settings in Lesvos, Chios, Samos, Leros and Kos, let alone providing protection measures in line with the international norms.

A situation of chronic emergency followed the EU–Turkey statement of March 2016, despite reassurance that all people on the move would be protected in accordance with the relevant international standards and in respect of the principle of non‐refoulement. This temporary and extraordinary measure was presented as necessary to end the human suffering and restore public order.3. More than four years since the EU–Turkey statement, the humanitarian situation on the islands has not improved, it has steadily worsened.

The asylum seekers living in EU‐supported hot spot facilities are exposed to multiple risk factors that can predispose them to becoming sick and facilitate the spread of any communicable disease. These include the lack of shelter, the highly overcrowded and unhygienic conditions, the lack of water, sanitation and hygiene (WASH) facilities and poor or no sewage system.

Since July 2019 when the Greek authorities withdrew the circular that regulated how AMKA (Social Security number) was to be granted to non‐Greek nationals, asylum seekers and children of irregular migrants have been prevented from accessing the public health system in Greece. An asylum law introduced in November has regulated the issue, but implementing measures are still lacking, putting the life and health of thousands of children and adults who still do not have access to health care at risk. The negligence of the Greek government to remove the existing barriers that the asylum seekers face in accessing public health care, in addition to the unhygienic living conditions, is setting the ground for future outbreaks of diseases, including vaccine‐preventable diseases such as hepatitis A, measles and meningitis, while at the same time having a severe impact on people who are suffering from chronic illness such as HIV and diabetes.

All over the world, governments are cancelling events, prohibiting large gatherings and encouraging social distancing, but in the Greek island camps, as in other detention contexts, people have no option but to live in close proximity. COVID‐19 may be just the latest threat that people face here, but the conditions they live in make them more vulnerable than the rest of the population. Forcing people to live in overcrowded and unhygienic camps as part of Europe’s containment policy was always irresponsible but now more than ever due to the COVID‐19 threat. In terms of prevention, or in areas where there are confirmed cases of COVID‐19, people should practise measures such as frequent hand washing or staying home in an isolated room when sick. However, in setting where families of five or six have to sleep in less than three‐square‐metre tent, and where up to 1300 have to share one water tap, these measures are clearly impossible to apply. People in camps such as Moria and Vathy therefore do not have enough water or soap to regularly wash their hands and do not have the luxury to isolate themselves. In some parts of the settlement in Moria, there are 167 people per toilet and more than 242 per shower, eight and five times, respectively, more than the recommended minimum standards in an emergency setting, making isolation away from individuals, should they contract COVID‐19, impossible. Since November 2019, the area outside the official camp has expanded further to encompass the whole of Moria camp, and there are around 5,000 people now with no access to water, showers, toilets and electricity and open defecation is being practised. In case of widespread transmission, the local health structures’ capacity to respond will be limited for the critically ill. Note that in Lesvos, there are one general hospital with only 6 beds ready and one ward to receive 20 persons, while only 5 ICU beds are available for approximately 120,000 inhabitants, including asylum seekers. In Samos, there is only one general hospital with only 2 ICU beds for approximately 40,000 inhabitants, including asylum seekers.

MSF along with international medical and academic community is alarmed at the potential spread of COVID‐19. We are in contact with authorities to coordinate actions, including promotion of health information in the camp and case management. However, one needs to be realistic: there is no way we can contain the virus in a humane and dignified way in the context of the living conditions in the camp settings. While we observe the WHO has announced rapid escalation in the global COVID‐19 response, the measures by the Greek government in case there is a suspected case of COVID‐19 inside camps are highly inadequate and partly just impossible to apply.

Authorities in Greece regularly announce protection measures for camps, including restricting movement by closing the gates between 19.00 and 07.00, allowing only 100 people outside of the camp every hour and allowing only one person per family to move to the urban centre – all of this controlled by the police. The imposition of more restriction of movement for the population of the camps and not for the rest of the population is unacceptable and discriminatory. Such restrictions make the refugee population trapped in the camps more vulnerable to the virus than the rest of the population. Such measures will increase the level of stress and fear amongst the population, which would implicate intragroup and domestic and sexual violence. Additionally, these measures will add to the migrants’ stress while fanning tensions between them and residents.

The new measures and a possible case/cases are just one more element to pit the people of the islands against the asylum seekers. The adherence to disease control measures recommended by WHO must be afforded to refugees and migrants but without imposing scientifically unfounded measures not only for their well‐being but also towards reinstituting already collapsing social cohesion in the islands.4.

MSF has been denouncing the health and humanitarian impact of the containment policy since its adoption on March 2016, COVID‐19 demonstrates, if it was still needed, how irresponsible these types of policies are from a public health perspective.5. The hot spots must be urgently decongested, in full respect of non‐refoulement and international human rights laws. Evacuations should start with those most at risk of contracting severe forms of the disease: people over 60, and people with existing medical conditions such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer.

Using COVID‐19 as an argument to control migration and evade international obligations towards refugees and migrants is not only unacceptable, but it would also be counterproductive in terms of outbreak control as it risks breaking the trust between health authorities and migrant populations, as well as the rest of the public, and making the response less efficient. To decrease the risk, asylum seekers must be actively included in outbreak prevention and response plans. Forcing people to live in overcrowded and unhygienic camps as part of Europe’s containment policy was always irresponsible but now more than ever due to the COVID‐19 threat. Let’s leave no one behind, even those already left behind!