2.5.17
A little ways north of Thessaloniki, Greece, 175 refugees live in a converted textile factory. In early January, the pipes burst under the strain of the coldest winter Greece has seen since the 1960s, leaving the camp without running water. Fuses blew regularly as the outdated electrical system from the old factory struggled to power the one space heater allocated per family, causing many to endure the biting cold without a heating source.
In the past two years, 1.3 million refugees and migrants have traveled to Greece. Of these, 173,450 refugees arrived by sea in 2016, and over 400 people died trying. There are many refugee camps in the region, some of which are little more than a collection of outdoor tents. The number of camps in Northern Greece is anywhere between 26 and 48, depending on which month the count was done and which authority reported the data. These camps housed about 60,000 people in 2015. After the Macedonian border was closed in March 2016, more refugees were left stranded in Greece, unable to continue on to other parts of Europe.
At most camps, a medical aid organization visits 1-2 times per week, leaving refugees with chronic diseases without access to a regular primary care provider. Each time a healthcare organization visits, an individual patient may be seen by a different provider who knows little, if any, medical history about the patient. This leads to decisions being made without reviewing previous treatment plans or medical progress over time, which decreases quality of care. Access to healthcare is impacted by the disjointed system of government and non-governmental agencies charged with managing various aspects of the refugee crisis and the Greek government’s starting position from an economic crisis of its own. Before the influx of refugees, the Greek government was already struggling to provide basic medical care to its own citizens.
This camp is unique both because it was awarded a 6 out of 5 on the standard of living scale for refugee camps during the Fall 2016 Greek Ministry of Migration survey, and because the most medically vulnerable refugees are preferentially sent here. The camp is capable of accommodating refugees with complex medical needs because of its superior housing and access to regular primary care with after-hours emergency medical response provided by the on-site clinic. The camp was created as a model to demonstrate the benefits of delivering all supportive services under one roof with an emphasis on collaborating with the residents to give them a say in their own welfare. Camp leadership works to foster a sense of ownership of the community, and a sense of home. It is privately funded, unlike most camps in Greece, which are run by the military.
At most camps, individuals get each meal handed out in a plastic container like airplane food, so there is no choice or control over what your children eat. Here, families are given a choice in what groceries make up their weekly allotment. The camp has a communal kitchen, which empowers residents to cook for their own families. Another difference is the organized shop where residents can use points to buy clothes, toys, or extra toiletries. Unfortunately, even given the private funding and superior housing, the community still endures conditions that can lead to poor public health.
The living conditions in refugee camps are a perfect storm for the transmission of infectious diseases. There is overcrowding, so it is easier for infections to spread through skin contact, the air, or objects such as bedding. Close to 100 people often use one bathroom, which increases the risk of fecal to oral transmission. At this particular camp, everyone uses one kitchen, which is vulnerable to contamination. Running water is only intermittent, and hot water fails even more frequently, so handwashing, which is the most important weapon against disease transmission, is often difficult, if not impossible.
The refugees at our camp are disproportionately children and individuals with chronic health conditions. Of the residents at the beginning of 2017, 12 percent were under age 5 and 61 percent were under age 18. Of the residents age 18 or over, only 38 percent were men. Two families were from Iraq, while the rest were from Syria. Many families were forced to flee their homes during the war in Syria years before as neighborhoods were bombed and parents worried that their sons were destined to join the fighting if they remained. These families all had their previously normal lives disrupted by violence and traumatic experiences. The stress individuals had endured was a significant factor to the fragility of the physical health of many in our camp.
The psychological stress of being unable to work and not knowing what the future holds also takes a toll. Some people feel that it is pointless to learn Greek or another language in the classes offered, because there is no telling what language may be spoken where they are eventually granted asylum. Many of the men stay up until four in the morning smoking and playing cards in a private room, reclusive from the rest of the community. Some are hesitant to put work into building up the community or making friendships, knowing they could leave any day with only 12 hours’ notice. The camp leadership has tried to foster community ownership among the residents, but the effort to encourage participation in running the camp and maintaining the building has been a struggle. On the other hand, some residents seize every opportunity provided enthusiastically; take every class offered, participate in every group, and take on leadership roles in the community. There are some resilient individuals who have managed to thrive, despite all the challenges of being a refugee.
The night of December 7, our team received a call about a medical emergency. The pediatrician on-call drove to the clinic to examine a two-year-old boy presenting with nausea, anorexia, emesis, lower abdominal pain, and yellow stool. The boy’s father reported that all of these symptoms began earlier that day. The doctor noted that the boy’s liver was enlarged on percussion, his eyes were slightly yellow, and when she tested his urine, the bilirubin was elevated. She expressed her concern to the father and explained that blood tests were needed, but at midnight, the lab was closed, so they needed to come back to the clinic in the morning so the boy’s blood could be drawn and driven to the nearby lab for testing. The doctor gave the boy a shot of zofran to help with the nausea and vomiting, but emphasized that this was not a cure, because the cause of the symptoms needed to be found, which would require more tests.
This encounter took place using a teenage resident interpreter. While there are confidentiality concerns when using residents of the same community for medical interpretation, the resident interpreters were essential for initiating the medical emergency system outside of clinic hours. All residents knew to go to their room in case of emergency because they were our point of contact. We trained the interpreters to take vital signs and complete a basic assessment so they could provide us with important information over the phone before we reached the clinic.
They took on this responsibility with gratitude and seized the opportunity to help their community. They volunteered in the clinic every day, eager to learn about medical care and gain professional experience. Patient care across a language barrier is always a challenge and despite the training given to these young residents, with the father’s anxiety, he was unable to listen and internalize the instructions the doctor gave. The next morning, the pediatrician went to the family’s room and knocked on the door, but there was no answer. The family was gone.
Our clinic was providing primary care for the residents of the camp, so we needed to make sure that the agencies responsible for tracking and controlling outbreaks of infectious diseases were notified in a timely manner with the details needed to respond to the situation. In a functioning system, primary care providers who directly treat patients report to a public health department if an infectious disease is diagnosed that could pose a threat to the patient’s community. A public health department can look at the big picture of an outbreak and act as a liaison between the many providers scattered throughout a region who may have treated a patient with the same disease. This coordination between primary care and public health is critical to track and control an outbreak at the early stages before it spreads.
Rather than reporting to a local public health department, for refugee camps in Greece, there are many agencies and levels of officials involved. The responsibility to take charge was not clearly owned by any one of these agencies, which made it easy to pass blame for work that was not done. I reported the case of hepatitis A to the Department of Epidemiological Surveillance and Intervention (KEELPNO), the agency responsible for surveillance and control of infectious diseases in Greece, the Ministry of Health’s Medical Coordinator on Vaccinations for Refugees and Immigrants, and the Ministry of Migration. I provided the information by emailing a clinical summary of the situation, by calling, and by submitting the Ministry of Health’s infectious disease surveillance form, which I completed daily to document the patients seen by our clinic in every 24 hour period, including details of any reportable conditions seen by our medical team.
While the Syrian government did an excellent job vaccinating the population prior to the war, with coverage rates for pediatric vaccines around 90 percent, any child under age six could be assumed to be unvaccinated because public health services ceased when the war began. Hepatitis A is common in the developing world, but rare in wealthier countries. In countries with poor sanitation, people develop immunity due to early childhood exposure. Most Syrian refugees were middle-class or upper middle-class, so similar to most American communities, the whole camp would be at risk of becoming infected with hepatitis A if exposed. Hepatitis A is not on the Syrian vaccination schedule, so even a fully vaccinated adult would not be immune.
On December 11, four days after the two-year-old became ill, a resident hurried into the clinic to tell us that the boy’s father needed help. He was too ill to leave his room, but he needed a doctor. The young man had abdominal pain, loss of appetite, nausea, dizziness, malaise, and a headache. On exam, he was febrile, his blood pressure was elevated, his abdomen was tender, and the edge of his liver was palpable although he was not jaundiced. Like the rest of the community, the man had not been vaccinated against hepatitis A previously. He was informed that he likely had the same viral infection as his son. This made him angry, so he left the camp again sometime in the next 12 hours when he was well enough to walk again. With the boy, his father, and his uncle all ill with the same symptoms, there were three cases, which, by definition, is an outbreak.
When medical volunteers and camp leadership learned about the boy with congenital adrenal hyperplasia being hospitalized for hepatitis A, three Greek citizens who work to improve the lives of residents at the camp every day took action. They each went to their doctor as a patient and got a vaccine for their own use. Even though as Greeks they were also at risk of contracting hepatitis A because they had not been vaccinated previously, they each gave their vaccines to members of the boy’s family, knowing that the family was high risk due to their close contact with the ill child. This selfless act demonstrates the goodwill of many Greeks to help the refugees in their country. They were willing to put their own health at risk to protect the health of a family of refugees.
One day in early January, a government official from what was analogous to a regional department of public health came to the clinic to meet with me unannounced. I was excited when she said she wanted to discuss vaccinations so I showed her to my office, which was actually a storage closet. The woman couldn’t have been much more than four feet tall, and due to the unusually high ceilings with shelves from floor to ceiling packed with medical supplies, I felt like I towered over her in the confined space without windows. I had emailed her many times with information about the hepatitis A situation at the camp and requests for vaccines. She said she did not think she had received any information or requests from me.
She asked how many people had been exposed to hepatitis A, and asked for details of the initial case in the two-year-old. I asked if she had read the report I sent, and she said she had not. I pulled it up on my computer and invited her to sit in my chair to read through it, because it had all the information she was asking about. She continued asking questions which would have been answered by emails I sent, and she insisted that she did not have the information about the vaccines requested. There was a long back and forth, with me clarifying what we needed and why, and her giving vague answers without making any commitments or indicating what her department was actually responsible for. She clearly did not actually want to talk about the work that needed to be done, it seemed her visit was more of a formality. I offered to exchange emails with her to make sure she had all the information. As I reached for a pen and paper, she said, “I don’t need it. I got your emails.” And then she left.
KEELPNO eventually came to the camp with 89 hepatitis A vaccines on January 20, but they arrived long after the window for post-exposure prophylaxis following the first case on December 7. They mandated that a pediatrician administer each vaccine. This requirement did not make any sense because a nurse can administer a vaccine, and we had emergency room physicians in the clinic who could have treated an adverse reaction to the vaccine in the unlikely event that one was to occur. That particular week we did not have a pediatrician, and an emergency room physician who regularly treats children wasn’t good enough. Thankfully, MDM Greece was kind enough to send a pediatrician to our clinic for the day to meet this requirement. I gave the KEELPNO representatives a copy of the list of 89 residents at high risk of complications, which was the request that prompted the vaccines to be brought to our clinic. They told me that they were only given authorization to allow the vaccination of children, so the 15 elderly adults and individuals with liver disease would not be allowed to receive a vaccine. This was frustrating from a public health perspective because many of the children offered vaccines were not as high risk as other individuals, and allocating the limited vaccines for use on the highest risk individuals would be better for the health of the community. In the end, hepatitis A vaccines were administered to 89 children between the ages of 18 months and 15 years.
Many aspects of the refugee crisis are often oversimplified by the media, but each refugee is a normal person, and people are multidimensional. There are fathers just trying to do what’s best for their family. There are resilient individuals learning new languages and contributing to their communities, thriving in spite of their circumstances. There are altruistic Greeks who spend every day working to improve the lives of the refugees living among them. There are also government officials who may be less than helpful at times. Providing primary care to refugees in Greece is complex, but not just because of the medical needs of the individuals. The bigger challenge lies in working within the socially-constructed systems to get things done.
This anecdote demonstrates one example of a systemic problem. In addition to hepatitis A vaccines, it is challenging to get any vaccines for refugees. The living conditions in refugee camps increase the risk of vaccine-preventable disease outbreaks. There isn’t an easy way to reach all refugees with a mass vaccination campaign, but maybe there is hope in raising awareness of the impact access to preventive healthcare can have on individual children and entire communities. Perhaps if the people who hold the authority to create or remove political barriers understood how much power they have to create positive change, they might think about using that power for good.
mary.mcquilkin@gmail.com