February 15, 2020
Adriaan van Es, MD, Secretary IFHHRO
15 February 2020
At the end of my three-week involvement as a medical volunteer providing medical relief work in Moria refugee camp through the Dutch Boat Refugee Foundation, I felt the need to make an assessment of the situation through the lens of the Right to the Highest Attainable Standard of Health (Right to Health), conceived in General Comment 14 (2000) to Article 12 of the UN International Covenant of Economic, Social and Cultural Rights (1966).
Although my passion is to provide medical care where needed and possible, I am also convinced of the responsibility of health professionals to account for their work from a human rights perspective.
Moria camp on Lesbos has been criticized many times, for instance, a year ago when MSF psychiatrist Alessandro Barberio sent an open letter in 2018 alarming the emergency situation of the camp.
He wrote: “In all of my years of medical practice, I have never witnessed such overwhelming numbers of people suffering from serious mental health conditions, as I am witnessing now amongst refugees on the island of Lesbos. The vast majority of people I see are presenting with psychotic symptoms, suicidal thoughts – even attempts at suicide – and are confused. Many are unable to meet or perform even their most basic everyday functions, such as sleeping, eating well, maintaining personal hygiene, and communicating.
[…] The asylum seekers include people who have been subjected to extreme forms of torture and violence, both in their countries of origin and during their journey. […] In Lesbos, they are forced to live in a context that promotes frequent violence in all its forms – including sexual and gender-based violence that affects children and adults.”
Meanwhile the population of the camp has increased to over 20.000; improvised small tents fill every small space, viral infections are rampant all over the camp and violence, stabbing and robbery are on the increase.
Medical care is officially the responsibility of the Greek authorities, but as a result of a severe lack of health personnel, some NGOs are allowed to provide medical care, i.e., the UK-based NGO Kitrinos and the Boat Refugee Foundation (BRF) from the Netherlands.
A small clinic in a container with adjacent tent-like structures opposite the police post is the home for the two NGOs: Kitrinos working in morning and early afternoon hours and BRF in late afternoon and evening hours.
In addition to the experiences described by dr. Barbario, we witnessed also many physical ailments, advanced cancer cases, and untreated non-communicable diseases in need of chronic care. Referral to hospital facilities for laboratory or x-ray investigations, and referrals to medical specialists, are severely hampered because of huge overburdened hospital services on the island.
The UN has criticized the situation in Moria and the Greek authorities have been criticized for failing to meet their responsibilities to account for the EU budgets provided for the refugees.
In a personal attempt to get Moria on the Right to Health agenda, I approached the UN Special Rapporteur in the Right to Health, Prof. Dainius Puras, who – agreeing that the situation is horrible – could unfortunately not fit Moria (Greece) in his agenda of country visits anymore.
Below, I will try to describe the situation in Moria camp, following the chapters and paragraphs of General Comment 14.
Underlying conditions of health
Food is provided in the ‘food row’ where refugees have to stand in line for hours, and where the provided food is – according to many informers – of substandard quality and quantity, partly due to the enormous increase of population, to which authorities did not react adequately. An NGO called Home for All provides additional good-quality meals for minors (under 18 children traveling alone).
Housing is below any standard. People are living in overcrowded cabins and tents, often in small ‘picnic’ tents, put down near the roadside or in the adjacent olive grove yard, typically named ‘the jungle’ for its low degree of organization and high degree of violence and unsafety.
Water and sanitation
There are various water tap points, but especially in the improvised areas the refugees have to walk far to fetch water. Toilet and shower/bath facilities are substandard in quality and quantity, and unsafe for women and girls.
Clean and safe environment
The environmental situation of the refugees is totally substandard. Overcrowding and temperatures that are eigher too low or too high create unhealthy conditions and stimulate viral and bacterial infections. Overcrowding stimulates violence and unsafety.
Registration of refugees is severely backlogged, and handing out of newcomers’ small budgets for basic life needs (required by EU and UNHCR regulations) is also very much delayed.
Legal support is available, primarily focused on the asylum procedure, through for instance the European Lawyers in Lesbos (ELIL), however only in the first phase.
The underlying conditions of health, as defined in the Right to Health, are absent and/or substandard.
Healthcare facilities are available in Moria camp. The Greek authorities provide limited and often much delayed necessary public healthcare, and a group of NGOs (Kitrinos and Boat Refugee Foundation) provide emergency and – to some degree – chronic care. There is a clear distinction of what is available for refugees and European civilians. For instance, medically necessary referrals to specialists, laboratory and x-ray facilities are virtually non existent for refugees, while these are open for non-refugees. This difference is in sharp contrast with the non-discrimination principle of the Right to Health.
Medicines – through donations to the NGOs mostly – are available in sufficient quantities. However, medicines for chronic care are in very limited supply. Not all medicines of the WHO Action Programme on Essential Drugs are available, notably opioids and psychotropic medicines.
As described above, healthcare facilities are accessible for refugees. However, the services are less accessible to refugees in comparison to non-refugee persons on the island. Since many of the refugees are vulnerable people, one can conclude that there is limited accessibility on grounds of discrimination.
Economical accessibility (affordability): the health facilities, goods and services for refugees are economically accessible for all refugees. However, if they are in need of more complicated assessments or specialist care, this is not accessible, unless they have a sufficient budget to pay (out of pocket) for private specialist care.
Information accessibility: all NGOs provide information, where possible, about health issues and places to address physical and mental health issues in all relevant languages.
Within the budget and other restraints, the healthcare facilities respect cultural and gender perspectives, and perform their work accordingly.
Given the fact that qualified physicians, nurses, psychologists and others are working in the clinics, one can conclude that on a human resource level, there is a reasonable level of quality. However, since the facilities they do their work in are insufficiently equipped according to their professional level requirements, one can conclude that the quality of care is severely substandard.
Maternal, child and reproductive health
Some specialized care for children, pregnant women and women who have faced sexual violence, is available through a clinic run by MSF, adjacent to the Moria camp. Capacity and continuity of care are however far from what is necessary.
Prevention, treatment and control of diseases
The huge overcrowding of the camp and overburdening of healthcare facilities pose severe restrictions on the right to prevention, treatment and control of diseases.
Non-discrimination and equal treatment
As described above, there is a structural discrimination between refugees and European citizens on the island of Lesbos, both in quality, accessibility and affordability. Within the healthcare facilities in the camp, there is no discrimination on basis of gender, sexual orientation, language, political orientation or social status.
Health care provisions: Availability, Accessibility, Acceptability and Quality of Health care, as defined in the Right to Health, are absent or substandard.
Greece is facing a humanitarian crisis with the huge immigration of refugees, with an additional absence of or low-level solidarity of other European countries refusing to take their – earlier agreed – share of refugees.
These limitations have, as far as I know – not been described as an accountable reason for substandard care for refugees.
States parties’ obligations
The government of Greece has announced its plans for 2020 to close the (open) refugee camps in the Aegean islands, transfer the refugees in an accelerated scheme to mainland facilities, and establish (smaller) detention camps on the island. Notably for vulnerable persons, such as children and minors travelling alone, this policy does not reflect the obligation of progressive realization of the Right to Health, but is rather a step of retrogressive realization, which is prohibited under the Right to Health.
States’ obligations to respect, protect and fulfil
The obligation to respect the right to health includes, inter alia, “refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services”.
This obligation is obviously not in place for the population of Moria camp.
The obligation to protect include, inter alia, “the duties of States to adopt legislation or to take other measures ensuring equal access to health care and health-related services provided by third parties”…, ; “to ensure that medical practitioners and other health professionals meet appropriate standards of education, skill and ethical codes of conduct”…, “and to take measures to protect all vulnerable or marginalized groups of society, in particular women, children, adolescents and older persons, in the light of gender-based expressions of violence”.
These aspects of the obligation to protect is not in place following the description above.
The obligation to fulfill requires States parties, inter alia, “to give sufficient recognition to the right to health in the national political and legal systems, preferably by way of legislative implementation, and to adopt a national health policy with a detailed plan for realizing the right to health”… States must […] ensure equal access for all to the underlying determinants of health, such as nutritiously safe food and potable drinking water, basic sanitation and adequate housing and living conditions”.
These (selected) obligations to fulfill are not in place following the description above.
For reasons of conciseness this assessment does not include international obligations.
Core obligations include inter alia:
(a) To ensure the right of access to health facilities, goods and services on a non‑discriminatory basis, especially for vulnerable or marginalized groups.
(b) To ensure access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom from hunger to everyone.
(c) To ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and potable water.
(d) To provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs.
These (selected) State core obligations are not met for the Moria camp populations.
For reasons of conciseness this assessment does not include the chapter on violations.
[…] Every State has a margin of discretion in assessing which measures are most suitable to meet its specific circumstances. The Covenant, however, clearly imposes a duty on each State to take whatever steps are necessary to ensure that everyone has access to health facilities, goods and services so that they can enjoy, as soon as possible, the highest attainable standard of physical and mental health. This requires the adoption of a national strategy to ensure to all the enjoyment of the right to health, based on human rights principles which define the objectives of that strategy, and the formulation of policies and corresponding right to health indicators and benchmarks. The national health strategy should also identify the resources available to attain defined objectives, as well as the most cost‑effective way of using those resources….
[…] The national health strategy and plan of action should also be based on the principles of accountability, transparency and independence of the judiciary, since good governance is essential to the effective implementation of all human rights, including the realization of the right to health….
An assessment of the framework legislation is beyond the competence of the author.
Remedies and accountability
Any person or group victim of a violation of the right to health should have access to effective judicial or other appropriate remedies at both national and international levels. All victims of such violations should be entitled to adequate reparation, which may take the form of restitution, compensation, satisfaction or guarantees of non-repetition. National ombudsmen, human rights commissions, consumer forums, patients’ rights associations or similar institutions should address violations of the right to health.
These forms of remedies seem to be absent for the Moria camp population.
[…] States parties should respect, protect, facilitate and promote the work of human rights advocates and other members of civil society with a view to assisting vulnerable or marginalized groups in the realization of their right to health.
These aspects of the Right to Health seem to be in place to a certain level.
Obligations of parties other than State parties
An assessment of the obligations of non-State parties is beyond the competence of the author.
- The Right to Health for refugees in Moria camp is violated in most of its aspects, both the underlying conditions for health and health care.
- The fact that Greece is in a particularly difficult position as one of Europe’s ‘frontier’ countries where most refugees and asylum seekers enter Europe, should be considered when it comes to accountability. Accountable parties seem to be not only the Greek Government but also the European Union.
- A health workers’ perspective and input in a Right to Health assessment is appropriate and relevant.
- NGOs working on Lesbos, including the Dutch Boat Refugee Foundation should establish a coalition for the protection and advancement of human rights of the refugees on the island.
- Such a coalition should use and mobilize international human rights facilities and communications, such as:
- Provide input for parallel reports for periodic reviews for among others the Committee on Social, Economic and Cultural Rights, the Committee on the Right of the Child and the Committee on the Elimination of Discrimination of Women.
- Provide input and seek cooperation from the UN Special Rapporteur on the Right to Health.
- Approach European human rights institutions and procedures.
- The Dutch Boat Refugee Foundation should publish a human rights and accountability statement.
Adriaan van Es, MD (former) physician volunteer at Boat Refugee Foundation
Secretary IFHHRO Medical Human Rights Network (www.ifhhro.org)