Sweet Sixty ?

The 60th anniversary of the UN Refugee Convention:
refugee crises in 2011 and challenges for the futureMédecins Sans Frontières (MSF) is an international medical relief organisation.
MSF is an independent and neutral aid agency that serves all people regardless of race,
political and religious affiliation.

December 2011

© G. Turine

Layout : w w w.okidokidesign.net - Yesmine Lawton|2

CONTENTS

3 CONTENTS
5 INTRODUCTION
6 Restrictive Government Policies
		 Southern Europe
		 South Africa
10 Shortfalls in assistance		Liberia
		 Tunisia
		 Kenya
18 What next?

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We hate the word
refugee.
Being a refugee islike being in a jailin the open air.
”© Olmo Calvo

Nadifa, 19, has lived in Dadaab, Kenya all her life|4

INTRODUCTION
As the 1951 Convention relating to the Status of Refugees
turns 60, millions of refugees – confined in camps, or
scraping an existence in rural areas and cities – are facing
a critical humanitarian situation. Refugees’ health andlives are being put in danger as a result of restrictive
government policies and serious shortfalls in assistance.
Médecins Sans Frontières (MSF) is extremely concerned by
the global trend to restrict the movements of refugees andasylum seekers and to deprive them of the protection theyneed and are entitled to.
There are 15.1 million recognised refugees across theworld. As party to the 1951 Convention and the 1967
Protocol, states have committed to protect refugees fromharm. Host governments have significant responsibilities
towards those who seek asylum in their countries, while
refugees have specific rights, enshrined in international,
regional and national legislation, including the right to alevel of healthcare similar to that of the host population.1
However, all too often national governments circumvent,
fail to uphold or simply ignore those rights. This has thedual effect of shutting the door to asylum seekers, andconstraining assistance to refugees within host countries’
borders – with adverse consequences on their lives and on
their health.

As an independent medical humanitarian organisation,
MSF does not differentiate between its patients – be theyrefugees, asylum seekers, migrants, or simply men,
women or children who are unable to get the healthcare
they need. In addition to the more than 15 million
recognised refugees, there are millions of other people,
fleeing violence in their countries of origin or seeking abetter life elsewhere, who are without legal protection
and assistance. Nevertheless, on the anniversary of the
Refugee Convention, there is a need to reflect on thecollective struggle on the part of governments, mandated
actors and civil society to provide basic welfare forrefugees and asylum seekers.
This document is not an exhaustive account of thecontemporary challenges faced by refugees andasylum seekers; instead it is a firsthand perspective
drawn from MSF projects in 2011. It aims to illustrate –through five examples in southern Europe, South Africa,
Liberia, Tunisia and Kenya –the restrictive policies ofgovernments towards refugees and asylum seekers,
and the shortfalls in assistance provided to them.

1 “The 1951 Refugee Convention states that refugees should enjoy accessto health services equivalent to that of the host population, while
everyone has the right under international law to the highest standards ofphysical and mental health,” UNHCR.

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Restrictive
Government Policies
States have primary responsibility for the welfare of
refugees and asylum seekers, but the enactment ofcertain policies, and the lack of implementation of others,
is leaving many people vulnerable. The trend has been
towards “increasingly restrictive, control-oriented andindiscriminate migration policies, at times at the expenseof core human rights protections.”2
These policies include systematic detention, restricted
access to asylum procedures, refoulement3 anddiminished or denied assistance. Refugees may also faceharassment from national authorities, discrimination and,in protracted cases, a lack of prospects for integration.
All of these have a clear impact on the physical andpsychological wellbeing of refugee and asylum seekers,
as we have seen in southern Europe and South Africa.

Southern Europe
In 2011, the popular uprisings in North Africa pushed some
57,000 refugees, asylum seekers and migrants to flee
across the Mediterranean sea to southern Europe. The
vast majority landed on the Italian island of Lampedusa.
Departing mainly from Tunisia and Libya, they undertook
perilous journeys by boat, and perhaps as many as 2,000
perished at sea. The arrival of people fleeing North Africa
was depicted as “illegal” or opportunistic migration, but
the need for legal protection and assistance was real,
prompting Italy to issue Tunisians permits to stay for up
to six months and to consider all those fleeing Libya as
asylum seekers. In Lampedusa, MSF came across many
extremely vulnerable people, including the survivorsof sexual violence, torture and ill-treatment, as well as
victims of human trafficking.
Aiming to curb the landings on its coasts, the Italian
government quickly moved to sign bilateral agreementswith the new Tunisian government and the Libyan
2 ‘Asylum, Migration and Refugee Protection: Realities, Myths and thePromise of Things to Come,’ Erika Feller, 2006, in the International
Journal of Refugee Law. Erika Feller is the Assistant High Commissioner
on Protection at UNHCR. The article was written in a private capacity.
3 The principle of non-refoulement is enshrined in Art. 33 of the 1951
Refugee Convention which states that “No Contracting State shall expel
or return (“refouler”) a refugee in any manner whatsoever to the frontiersof territories where his [or her] life or freedom would be threatenedon account of his [or her] race, religion, nationality, membership of aparticular social group or political opinion.”|6

Transitional Council. First Italy announced that all
Tunisians arriving after 5 April 2011 would be designatedas economic migrants and repatriated. In June 2011, theItalian government revisited its Friendship Treaty with Libya,
which included migration control provisions, and signed
a new memorandum of understanding with the Libyan
Transitional Council, in part to “combat illegal migration”.
These agreements amounted to pushing back potential
asylum seekers from Europe’s shores. As MSF teams
learned through talking to patients in Italy and Malta, these
agreements have had serious health consequences formany asylum seekers, including violence and ill-treatment
in detention facilities back in Libya.
In addition, certain European countries, including Italy,
were party to the Libyan conflict – and thus bore, as MSF
publicly indicated, an even greater responsibility. Indeed,
Europe Union member states’ weak response to the boats
arriving on their shores contradicted the claimed purposeof NATO’s military intervention – which was predicatedupon the protection of civilians.
MSF has worked at landing points along Italy’s coastline
since 1999, in both reception centres and open settings,
to provide medical care and mental health support tothose arriving on the country’s shores. Over the past few
years, MSF has also been working in Malta and Greece insimilar projects. We have repeatedly called attention to theappalling living conditions in reception centres and their
far-reaching impact on the inmates’ physical and mental
health.4 Moreover, the quasi-systematic detention upon
arrival of not only migrants but also refugees and asylum
seekers is a threat to the health of people who have fled
danger and hardship in their countries of origin.
Many new arrivals landed in Italy, after boat journeys
fraught with danger, suffering from seasickness,dehydration, hypothermia and generalised body pain. In
March of this year, 3,000 new arrivals slept on the docksin Lampedusa for several days, sharing 16 toilets andsurviving on 1.5 litres of water per day.5 In September, a firein one of the overcrowded reception centres in Lampedusa

4 See: ‘Not Criminals’, MSF, April 2009; ‘The Impact of Detention on
Migrants’ health,’ MSF, January 2010; and ‘From North Africa to Italy:
Seeking Refuge, Finding Suffering,’MSF, May 2011.
5 UNHCR emergency guidelines state that the absolute minimum
allocation is seven litres per person per day and one latrine per fivepeople, UNHCR Handbook for Emergencies, 2007.

© M. Insolera

brought attention to the precarious conditions and stress towhich migrants, asylum seekers and refugees were exposed.
The Lampedusa centre has since been closed down and theisland’s port declared unsafe for rescue at sea operations,putting even more lives at risk.
European Union member states have yet to ensure
appropriate medical and mental health support, and have yet
to respect minimum standards for the reception of asylum
seekers and vulnerable people, including unaccompanied
minors and victims of torture, sexual violence and humantrafficking. Adhering to the standards set out in the EC“Reception” Directive6 is unlikely to create a “pull-factor”
towards Europe, as is commonly stated; rather it is ahumanitarian necessity.
6 European Council Directive 2003/9/EC of 27 January 2003 sets minimum
standards for the reception of asylum seekers.

Unlike 60 years ago, today it is developing countries whichhost 80 percent of the world’s refugee population. Close
to one million people crossed the border from Libya into
Tunisia between February and September 2011,7 in contrast
with the nearly 60,000 arrivals to Europe. Europe’s fundingof humanitarian refugee operations worldwide should bein addition to, rather than as a substitute for, providing
adequate reception conditions to those who flee conflictand persecution at home.

7 Update on UNHCR’s operations in the Middle East and North Africa,
UNHCR, September 2001.

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On the southern tip of the African continent, South Africa’s stableenvironment, economic success and progressive constitutional laws
regarding refugees have attracted hundreds of thousands of migrants andasylum seekers from all over the continent. In recent years, the majorityof those seeking refuge in South Africa have come from Zimbabwe, whileothers have travelled from other African nations such as Somalia wherea deteriorating humanitarian situation and the collapse of the state havemade life untenable. A complex mixture of economic, political and security
reasons have brought people to seek refuge and subsistence in South Africa.
In 2007, MSF started providing humanitarian assistance to refugees, asylum
seekers and migrants in South Africa through two projects: one in innercity Johannesburg and the other in Musina, at the main border crossing
with Zimbabwe. These projects provide primary healthcare, mental healthsupport and referrals to hospitals including for chronic conditions such as
HIV and tuberculosis (TB). Patients suffer from a wide range of pathologies
including respiratory infections, diarrhoeal and gastro-intestinal conditions,sexually transmitted infections, skin conditions, physical and psychologicaltrauma related to sexual violence, and stress-related ailments. Many ofthese pathologies can be directly attributed to their journey crossing into
South Africa, and to the poor living conditions in Johannesburg.
For the past two years, Zimbabweans residing in South Africa had been
covered by temporary protection measures which allowed them tostay and work legally in the country. However, since October 2011, thegovernment has resumed deportations for those migrants who are without
documentation. MSF is concerned that South Africa is denying entry to
refugees8 and asylum seekers at its borders: our teams have witnessed
Zimbabweans without passports being barred entry at the Musina border
post. MSF is also concerned that, since January 2011, people have been
driven back to the border and denied the possibility of applying for asylum.
This practice is tantamount to refoulement, which is a breach of South
African national law and violates one of the core articles of the Refugee
Convention – itself accepted as an established principle of internationalcustomary law.
Asylum seekers from Somalia and other countries, including Ethiopia andthe Democratic Republic of Congo, have informed our medical teams thatthey were refused entry under a ‘first safe country’ principle, under whichpeople are expected to apply for asylum in the first safe country in which
they arrive. This does not account for the dangerous journey to the countryof asylum, and has no basis in either national or international law. This
harmful policy is now spreading to the whole region, with some refugees
and asylum seekers being arrested and deported at the bordersof Mozambique, Tanzania and Malawi.
The health consequences for refugees, asylum seekers and migrants
are serious. In South Africa, the majority of our patients at the bordercrossing of Musina report the systematic theft of their belongings, including
medication. Many have had their TB and HIV treatment interrupted, which
can result in life-threatening medical complications. Furthermore, thesepolicies encourage irregular entry into the country, which in itself is fraught
with danger – from drowning in the Limpopo river to falling prey to criminal
gangs. In the first six months of 2011, MSF treated 42 victims of sexual
violence who had been assaulted by gangs while crossing the border. Thesepatients reported that a further 159 victims had been exposed to similar
sexual assaults but did not seek assistance.
8 Somalis are recognised as prima facie refugees by South Africa.

|8© S. Robinson

South Africa

9|© J. Remy

Shortfalls in assistanceObtaining refugee status gives,at a minimum, the right to residein the host country.

”|10Obtaining refugee status gives, at a minimum, the right toreside in the host country. This legal protection throughdocumentation is often not enough to enable refugees
to subsist. As MSF has observed in Liberia, Tunisia and
Kenya, timely and adequate medical assistance is often
unavailable, frequently because of a lack of resources orpolitical will.

Liberia
Following the violence in Côte d’Ivoire in early 2011, some
188,000 refugees crossed the border into Liberia, while
half a million people were displaced within the country
itself. In western Côte D’Ivoire and northeastern Liberia,
MSF ran mobile medical clinics on both sides of theborder. Many Ivorians told our teams their experiencesof suffering violence, repeated displacement, kidnapping
and rape during the post-election violence in Côte
d’Ivoire. In the Liberian border region of Nimba county,
which already had scarce social services and generally
low health indicators, the arrival of up to 93,000 refugees
was perceived as a threat to ongoing stabilisation efforts
by the international community. At the same time as
refugees arrived, humanitarian actors were scaling down
and aid efforts were turning toward development. In thisvacuum, the immediate emergency response was stalled.

a foreseeable and slow-onset influx of refugees acrossa border. The Liberia case exposes the failure to apply
lessons learned in prior refugee crises, most notably
to address jointly the needs of refugees and the hostcommunity. It was a conscious decision on the part of
the Liberian government and the UN’s refugee agency,
the UNHCR, not to provide assistance in the politicallysensitive border area where the majority of refugees
were located. Despite a range of established bestpractices in such a classic situation, assistance andprotection for refugees failed to materialise in a timely
manner in Liberia. The experience of Ivorian refugees
raises the questions if and how today’s international
responses to refugees will be able to adapt to the manyand increasing challenges in more complex settings, incities or in mixed migration flows.

From the start, United Nations contingency planning
foresaw a voluntary settlement of 70 percent of refugees
to camps for “security and logistical reasons”.9 Yet in
Nimba county, no more than 5,000 refugees moved to theidentified camp and settlements, leaving the majority of
refugees in host communities with no systematic provisionof international aid. Host and refugee populations shared
scant available resources, rendering both populations
more vulnerable. In the absence of dependable assistance,
MSF found that refugees regularly crossed the borderback into Côte d’Ivoire, at great personal risk, to retrieve
food or seeds from their abandoned homes or to search
for lost relatives. At the same time, no mechanisms forinternational protection were established until six months
after the start of the emergency.

© G. Turine

Fortunately, MSF did not observe a major health crisis
in Nimba county, but the experience highlighted theinadequacy of a coordinated response to what in many
ways was a typical contemporary refugee crisis:
9 ‘Draft Interagency Contingency Plan, Potential Increase of Ivorian
Refugees in Liberia (Nimba, Grand Gedeh, River Gee, and Maryland
Counties,’ UNHCR, March 2011.

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© I. Gayton

Tunisia
The vast majority of those who fled the Libyan conflict went
to the country’s immediate neighbours, Egypt and Tunisia.
Prior to 2011, Libya had been a transit point as well asa destination for many sub-Saharan Africans. When thefighting broke out in Libya, hundreds of thousands ofpeople fled to Tunisia – among them nearly 700,000 Libyan
nationals escaping violence, as well as 11,500 refugees
and asylum seekers from Eritrea, Ethiopia, Iraq, Côte
d’Ivoire, Somalia and Sudan.
MSF began providing medical assistance in March 2011,
with a focus on mental health. The main project was in
Shousha camp, where Tunisian authorities centralised
the refugee population. From the onset, assistance at thecamp was inadequate; there were security problems, alack of access to secondary healthcare, the obstructionof medical referrals by the Tunisian military, poor waste

management and water shortages. Over the following
months, many refugees and asylum seekers returned to
Libya – which was still at war – because of the difficult
living conditions and the lack of prospects in Shousha.
MSF mental health teams were also being told by patientsthat they preferred to cross the Mediterranean sea toEurope rather than stay indefinitely in the camp in thesepoor conditions.
The failure to provide assistance and protection in Shousha
camp remains particularly damning given the involvementof the international community in the Libyan conflict.
Refugees were given the impossible choice between
staying in Shousha with few prospects, returning to wartorn Libya, or attempting the dangerous sea crossing toEurope. Several thousand mainly sub-Saharan Africans
remained stranded for months, unable to return to theircountries of origin.

13|© L. Addario

Kenya
Shortfalls in assistance to refugees are not confined tosudden emergencies, as the case of Somalis illustrates.
In the words of UN High Commissioner for Refugees
António Guterres, “there isn’t any group of refugees
who are as systematically undesired, stigmatised anddiscriminated against as the Somalis.” Our teams haveprovided healthcare to Somalis in many countries: inSomalia, Kenya and Ethiopia, but also further afield in
Libya, Yemen, South Africa and Italy. Since obtaining
refugee status is often not enough, migration becomesa way for them to survive in search of a better life.
The dire humanitarian situation for refugees in Dadaab,in northern Kenya, is by now well known. The plight of
the nearly half a million mostly Somalis in the Dadaab
camps was broadcast across the world’s media this year
because of the extraordinarily high number of arrivals
escaping violence and hunger in Somalia.
Yet the current refugee crisis in these settlements –characterised by what some have called a “humanitarianregime of detention”10 – is neither new nor temporary.
The Dadaab camps were built more than two decades|14

ago, and the settlements have more in common withurban slums than with the traditional image of a refugee
camp – by definition temporary accommodation. Dadaab,it is worth emphasising, is Kenya’s fourth largest city, andit has now been a decade since its population surpassed
the site’s maximum capacity.
Despite the attention and the allocated funds, Dadaab
fails to be a safe environment. Alarmingly, some healthindicators for refugees worsen after their arrival in thecamps. For example, in January 2011 MSF conducted ahousehold survey in an area of Dadaab that showed rates of
3 percent severe acute malnutrition (SAM) and 12 percent
global acute malnutrition (GAM) among children underfive years old. A repeat assessment in the same area six
months later showed rates of 6.3 percent SAM and 24.3
percent GAM. Another more recent study conducted by
MSF’s epidemiological branch confirmed that the refugees’
precarious living conditions are indeed having profoundconsequences on their health.
MSF worked in Dadaab for 12 years before returningin 2009 in response to the nutritional and health© M. Goldemergencies affecting the camps’ population. The
humanitarian infrastructure is simply not set up to deal
with people who have been living in crisis for 20 years.
Refugee camps waste lives away: half of Dadaab’s
refugees are under 17; they have grown up in the camps
and have little prospect of leaving them.
Providing assistance to Dadaab’s refugees to ameliorate
their daily lives remains a priority for us. Despite serious
security concerns for our teams, MSF strives to provide
a high level of medical care to a refugee population who
have little prospect of going home. However, we do notwant to be complicit in maintaining a status quo in which
a permanent humanitarian emergency conceals politicalissues. The government of Kenya has responsibilities
towards these refugees. At the very least, it should
uphold its obligations under the Refugee Convention andimprove reception conditions at the border.10

Refugees in cities
10 Refugees need to be issued a pass to exit the camps, even for medical
emergencies, and this is seldom granted. Refugees without proper
documentation risk arrest and detention.

Refugee camps
waste lives away:
half of Dadaab
refugees areunder 17 and havelittle prospects.

”

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The gradual increase of urban refugees – both in absolute numbers
and in percentage terms – has been a challenge for humanitarianorganisations. In contrast to refugee camps, it is harder to identify,
register and target services to a geographically diffuse and invisible
population. Refugees gravitate towards cities for socio-economic
reasons, but MSF’s work in various urban contexts shows that theyoften lack the most basic services, including healthcare. Indeed, thewelfare of refugees goes beyond their legal documentation: in urban
areas it requires having access to existing social services as well as
the state’s protection from discriminatory practices.

© S. Assir

In South Africa, for example, the city of Johannesburg has identified
1,305 slum buildings with an estimated population of a quarter ofa million, many of them Zimbabwean asylum seekers. A survey
conducted by MSF documented the conditions of 82 slum buildings
which were home to between 50,000 and 60,000 inhabitants. The
living conditions were below the minimum standards set for refugee
camps: close to 85 percent had less than the required 3.5 square
metres per person; 38 percent shared a water tap with more than
200 people; and just under half shared a toilet with 100 people – far
below the minimum required in an acute emergency. MSF worked
with the residents in five of these slum buildings to remove waste –and called on the authorities to ensure greater integration of urban
refugees, asylum seekers and migrants into existing social services.

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Mental health
Refugees and asylum seekers leave an unstable situation in their home countries, and often risk
their lives in their quest for a safe place to stay. With so many experiencing danger in the course of
their journeys, one of our key concerns is that refugees lack adequate mental health support. MSF’s
mental health programmes aim primarily to reduce people’s symptoms and improve their ability tofunction. This work is done by local counsellors, with MSF psychologists and psychiatrists providing
technical support and clinical supervision.
Recent mental health assessments done by MSF in Italy, Malta and Greece point to the risk ofdepression, anxiety and post-traumatic stress disorder amongst asylum seekers. These areaggravated by detention, both upon arrival in Europe and also in transit countries, as well as by thelack of information about their legal situation.

“I tried two times to come to Italy. The first one was in August 2009; our boat was
already out at sea but a Libyan boat arrived and took us back to Libya. I was jailed
for about one month in a prison near Tripoli airport. (…) We were 65 people in arectangular room measuring five by eight metres. (…) We did not have water and so
we had to drink from the two toilets we had for 65 people.”
Somali refugee in Caltanissetta, Italy, April 2011

An April 2011, a mental health assessment was conducted among Libyans who had fled acrossthe border to Dehiba in Tunisia. It found that the overwhelming majority of mental health patients
showed symptoms of anxiety and depression which were directly related to the conflict in Libya. In
Shousha camp, in Tunisia, MSF found that psychologically vulnerable people routinely faced difficultyin accessing other forms of medical care and services. From March to August 2011, MSF conducted
more than 12,500 individual and group mental health consultations with victims of the Libyan conflict inTunisia.

“I don’t know how to plan, or what will happen tomorrow, or how we will survive
today. (…) A lot of people are trying to go back to Libya and cross the Mediterranean
sea to reach Lampedusa to get a better life.”
Eritrean refugee in Shousha camp, Tunisia, July 2011

The mental health of refugees and asylum seekers is often affected by their journey to safety.
Traumatic events can occur within the borders of the host countries. For example, 83 percent of thecases of sexual violence documented by MSF at the Zimbabwean-South African border in a threemonth period in 2010 occurred within South Africa.

“I crossed the river with a group of four people. We were met by a gang of sevenguma guma (criminal gang members) on the South African side who were armed
with knives and guns. They forced me to have sex with the women in my group andI refused. Then one of the guma guma raped me. I don’t actually know how manyof them forced themselves on me because I was confused by the whole incident. I
fainted and when I woke up they were nowhere to be found.”Zimbabwean asylum seeker in Musina, South Africa

17|What next?
For too many people, to be a refugee in 2011
is to confront the harsh realities of oppressive
government policies and severe shortfalls
in lifesaving assistance. Yet the examples
detailed in this report do not mean that theinternational legal refugee framework is a
failure. The Refugee Convention, its subsequent
Protocol and the regional conventions remain
important safeguards for refugee protection
and assistance by governments, the UNHCR
and civil society actors.
MSF calls on all states to recognise the physicaland psychological vulnerabilities of people
who have fled from their countries, and tooffer them adequate medical assistance andprotection. Policies and practices such as thosedescribed above make it increasingly difficultfor people even to apply for asylum and haveserious medical and human consequences.
These policies are forcing refugees and asylum
seekers to live in hiding and to perceive thestate as oppressive rather than protective. While
not necessarily contravening international andnational laws, states are violating the spirit of
the 1951 Refugee Convention and the meaningof asylum.

© L. Addario

MSF’s medical and humanitarian work has atangible but ultimately limited impact on thewelfare of refugees and asylum seekers. The
challenge in the years ahead will be for states
to fulfill their responsibilities and allow the
UNHCR and civil society the necessary space toprovide protection and assistance to refugees
and asylum seekers. This would be in the spiritof the 1951 Refugee Convention, and would
really provide something to celebrate.

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© Olmo Calvo

Médecins Sans Frontières
Dupré Street 94 - 1090 Brussels - Belgium
www.msf.org