Obstacle
Courseto Europe
A policy-made humanitariancrisis at EU borders© Alessandro Penso

December 2015

Contents

Glossary
Asylum seeker :A person who seeks safety from persecution orserious harm in a country other than his or her
own and awaits a decision on the application forrefugee status under relevant international andnational instruments.
Migrant : 	
a person who is outside the territory of the Stateof which they are nationals or citizens and who
has resided in a foreign country for more than
one year irrespective of the causes, voluntary or
involuntary, and the means, regular or irregular,used to migrate.
Refugee : 	either a person who, owing to a well-foundedfear of persecution for reasons of race, religion,
nationality, political opinion or membership of aparticular social group, is outside the country ofnationality and is unable or, owing to such fear,is unwilling to avail themselves of the protectionof that country, or a stateless person, who,being outside of the country of former habitualresidence for the same reasons as mentioned
before, is unable or, owing to such fear, unwilling
to return to it.
NB : As a medical humanitarian organisation,
Médecins Sans Frontières (MSF) does not operate
any distinction between people on the basis of theirlegal status. Our assistance is based on medical
and humanitarian needs alone. Generic legal
terminologies will never sufficiently reflect thecomplexity of our patients’ migratory movements, thetrauma they have suffered along the way and theirneeds for protection and assistance. The terms usedin this report are without prejudice to these realities.

• executive summary4• KEY FACTS AND FIGURES

7• Introduction

8• The European Union’s Asylum framework and Policies 

10• The Obstacle course to Europe

15

Step 1 : Flight

15

Step 2 : Crossing the Sea

17

Step 3 : Arriving in Greece and Italy

0

Step 4 : Transiting from South to North0• A dramatic European failure to respond to the crisis

50• conclusion : A urgent call for change

53© Francesco Zizola / Noor

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EXECUTIVE SUMMARY
The world currently faces its largest global
displacement crisis since World War II, withapproximately 60 million people currently
displaced due to conflict, persecution anduntenable conditions in their home country.
Whilst foreseeable, Europe is still reeling inshock from the sheer numbers of refugees
and migrants – approximately one million –who have crossed its borders in 2015.
It will be remembered as the year inwhich Europe catastrophically failed in its
responsibility to respond to the urgent needsof assistance and protection of hundreds ofthousands of vulnerable people. Not only
did the European countries and its member
states collectively fail to address the urgent
humanitarian and medical needs of refugees
and migrants arriving at external or internal EU
borders, but the European Union’s deterrence
and anti-immigration policies – developed overthe last 15 years and further strengthened in2015 – have increased the demand for migrantsmuggling networks and pushed people
towards ever more dangerous routes whichjeopardise their health and lives. These policies
have largely contributed to the patterns of thereception crisis we are witnessing today : withthose desperate to come to Europe forced tocross the sea and southern EU countries failingto respond to their needs.

© Will Rose / Greenpeace

Facing razor wire fences, closed borders
and intimidating soldiers and police forcesfrom Turkey through most of the Balkans;
highly dangerous sea crossings to Italy or
Greece; squalid and inhumane reception
conditions; and complicated and everchanging registration procedures, thousandsof men, women and children fleeing conflictand desperate conditions have had to face
another obstacle course, this time throughEurope.  Countless meetings, conferences andplans have been organised by the European
Union and its member states throughout
2015. Despite this, most states have been

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unwilling or unable to provide assistance tothe refugees and migrants who make it into
the European Union. As of 3 November 2015,
14 member states had collectively made 2,284
places available out of the 160,000 European
relocation pledge and only 86 people had
effectively been relocated from Italy.
The traditional state and UN-sponsored aid
system has also struggled to adequately
respond to people’s needs. Instead, civilsociety and volunteer groups, better able towork around administrative, institutional andpolitical blocages, have emerged as key toproviding refugees and migrants with essential
services throughout their journey. At thecore of these non-state activities has been
an overwhelming upsurge of solidarity fromcitizens across the world volunteering theirtime, donations and money to assist the tensof thousands of refugees and migrants in need.
As an emergency medical humanitarian organization, Médecins Sans Frontières (MSF) scaled
up its operations in Europe throughout 2015
and focused on setting up mobile responses
to attend to the needs of these unprecedented
numbers of people on the move.
Never before has MSF had so many projects
in Europe, never before has MSF decided tomobilize three search and rescue ships at
sea to save lives, and never before has it been
more urgent for European governments tostep up to their international obligations andassist these people whose lives are at risk.
Indeed, the situation at Europe’s borders
in 2015 has cast a spotlight on a number ofhighly inconvenient facts that European governments have been trying to ignore for years:• Closing borders does not stop people moving, it simply shifts their routes;• Deterrence policies have direct detrimental humanitarian and medical impact; and• Increasing humanitarian aid to camps in
Lebanon, Turkey or Jordan, even if urgently
needed does not absolve EU member statesof their responsibilities to receive, assist
and protect refugees within EU territory;
and it will not stop people seeking safety inEurope for complex reasons
In denying vulnerable people dignified reception conditions, and blocking and pushing backpeople based on their nationality rather thanvulnerability and risk of persecution, European states have eroded the very foundations ofinternational refugee and human rights law.
With a new year ahead and a few months before another potential peak in arrivals, Europe
and its member states have the opportunity
to right the wrongs of 2015. Europe must dismantle its obstacle course and provide assistance and safe, legal passage to refugees andmigrants fleeing desperate conditions.
This report tells the stories of men, women,children, the elderly, the sick and the disabled, travelling alone or with their family,
fleeing war, persecution or extreme poverty
and seeking refuge and a better life in Europe;
people who were left with no other choice thanto run the obstacle course to Europe. It highlights how the EU’s response so far has not
only failed to respond to the urgent humanitarian and medical needs of these vulnerable
populations, but has also contributed to theworsening of their situation, with a sometimes tragic impact on their health and lives.
The report spells out that Europe cannot
continue to count on the deadly sea crossing, fences and poor reception conditions to
act as a ‘filter of deterrence’. The current
narrative and policies cannot hold. As instability continues to rage across Syria, Libya,
Iraq and Afghanistan, the EU and European
governments must shift their current policies and provide a humane and humanitarian

response to refugees and migrants desperately seeking its protection and assistance.
The EU and European states are strongly
urged to:• Swiftly provide safe and legal channels
for people seeking asylum, in particularallowing asylum seekers to apply for asylum at external land borders, including
the Evros land border between Turkey
and Greece. This also includes making
wider use of legal entry schemes, suchas (for example) family reunification, humanitarian visas, simplified visa requirements, resettlement and relocation.
• Create legal migration pathways to decrease the demand for irregular migration and smuggling networks.
• Create an ambitious search and rescue
mechanism to save lives at sea. This
operation should proactively search forboats in distress as close to departure
points as possible and should be accompanied by pre-identified disembarkation
points where humane disembarkation
procedures, including adequate reception conditions, medical care and vulnerability assessments, are in place.
• Invest in reception according to EU standards instead of deterrence measures only.
Europe must move away from a fortressapproach to a reception approach designed to address the needs and specificvulnerabilities of people arriving at its
borders, in particular their medical andmental health needs.
• In the absence of a functioning common
European asylum system, invest more ambitiously in intra-EU relocation schemes
and the creation of safe passage throughthe EU.
• Put an end to acts of violence and abusefrom state authorities and criminal groups.

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KEY FACTS AND FIGURES
Quantifying and qualifying the movement of people :• Between 1 January and 31 December, an estimated 1,008,616  people fled to Europe• 84% came from refugee-producing countries, with 49% from Syria, 21% from Afghanistan
and 9% from Iraq
• 17% were women and 25% were children under the age of 18

Health impacts of Europe’s migration policies :Between 1 January and 15 December 2015, MSF teams provided just under 100,00 medical
consultations to refugees and migrants on its search and rescue vessels in the MediterraneanSea, in Italy, Greece and throughout the Balkans. Between May and December 2015, MSF
rescued and assisted 23,747 refugees and migrants at sea. They bore witness to and treatedthe physical and mental health consequences of the terrible journeys and the lack of basic
assistance, as well as injuries and mental health trauma sustained by violence. Most of thepathologies treated by MSF medical teams could have been easily prevented if a safe passage
and reception up to humanitarian standards had been put in place by EU states.
Our medical teams in Greece and Serbia treated 12,214 patients for trauma related conditions,which represents 18% of all medical consultations in these two countries. Among the 408 most
severe trauma cases, 70% of these patients reported physical violence, robbery or verbal abuse
and intimidation experienced during their journey.

MSF’s mobilisation on migration in Europe :In 2015, MSF spent an estimated 31.5 million euros and mobilised 535 staff to respond to theneeds of refugees and migrants in Europe :• 45 MSF staff and 11.5 million euros were mobilised to carry out search and rescue operations
on three vessels in the Mediterranean Sea.

© Alessandro Penso• A further 489 staff and 20 million euros were mobilised to respond to the humanitarianneeds of refugees and migrants in Italy and Greece, the Balkans and in their countries ofdestination.

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Introduction :a policy-made humanitarian crisis“We fled to Europe for the security of thechildren. To make sure they are safe andhave access to good education. Because
there is nothing left in Syria. My entire
town is destroyed. But if I had known
that it’s so hard to reach Europe, I would
never have sent them. I’d rather havedied in Syria than to go through this. I
thought people in Europe would treat us
well. Because of all the difficulties on
the road, some of us gave up and went
back to Syria. They are dead now. In total,
I was arrested 33 times. I was thrown inprison in Greece, in Macedonia, in Serbia,
in Hungary. Why? I don’t understand. I did
nothing wrong. I did not steal nor kill. I
flee death, but I only find death. My futureis the future of my children. If only I knew
where they are...”Syrian man living alone in a forest after he lost track of
his wife and four children, winter 2014, Serbia.

In 2015, just over a million people  risked their life
to reach Europe from Africa, Asia and the Middle
East; 84% of them came from the world’s top 10
refugee-producing countries. While the official
discourse in Europe has tended to present thecontinent as overwhelmed by an ever-growing
wave of migrants and refugees, their number
accounts for less than 0.02% of Europe’s total
population. Indeed, the vast majority of people
fleeing conflict zones are internally displaced orlive in neighbouring countries. In 2014, Turkey,
Pakistan and Lebanon alone hosted one third of
the world’s refugees1. In Lebanon, a country witha population of 5.8 million, refugees represent
almost 30% of the population.
As we reflect back on 2015, the year willundoubtedly be remembered in Europe as
dominated by a ‘refugee crisis’ driven byexternal forces. Yet the humanitarian crisis thathas unfolded on the borders of the EU is theresult of no natural or unforeseen disaster. It
is in large part a policy-driven crisis sustainedby the failure of the European Union to put
in place adequate and humane policies andresponses to deal with this unprecedented but
in many ways foreseeable movement of people.
For years, the EU and European governments  
have chosen to invest years ago in measures
aimed at systematically sealing off borders anddeterring refugees and migrants from seeking
safety in Europe. These policies include thebuilding of fences at external but also internal
EU borders, stricter border controls aiming at‘fighting’ irregular migration, the containmentof migrants and refugees in countries of firstarrival or in transit countries outside of the EU,
the increased use of immigration detention, andchronic substandard and insufficient reception
conditions in countries of first asylum, primarily
in Italy and Greece.
As a result, refugees and migrants, many fleeing
war and persecution and in search of assistanceand protection, have faced further violence,
arbitrary detention, ill-treatment, extortion,
sexual violence, human trafficking, push-backs
at borders, and inhuman reception conditions
in countries of first asylum. With land borders
into Europe (namely the Spain-Morroco, TurkeyBulgaria and the Turkey-Greece borders) mostly
sealed off, the only possible entry to Europe
for most is across the sea. Whilst the majorityof people reached Europe through the Central
Mediterranean route (mainly Libya to Italy) in thefirst half of 2015, the movement of people shiftedto the Eastern Mediterranean route (mainly
Turkey to Greece) from July 2015, with an averageof 5,000 people arriving every day on Greek
shores in September 2015. As of 31 December,at least 3771 people had died whilst attempting
the sea crossing to Europe in 2015. Today morethan ever, the EU and European governments’restrictive policies are jeopardising the right toseek asylum and putting refugees and migrants’
health and lives at risk.
For the last fifteen years, MSF has been working
in European Union (EU) countries, providing
medical care and humanitarian assistance torefugees, asylum seekers and undocumented
migrants. In the last year and especially since
the summer of 2015, the organisation has had todramatically scale up its operations in Europe.
The need for MSF, as an international medical
humanitarian organisation, to conduct search andrescue operations at sea and to provide assistanceat Europe’s entry points is a telling indictment of
the lack of adequate state assistance currently
available for these vulnerable populations. Neverbefore has MSF had so many projects in Europe,and never before has it decided to mobilise searchand rescue vessels at sea to save lives. Never has
it been more urgent for European governments
to step up to their international obligations andassist these people whose lives are at grave risk.

While some new and positive measures havebeen put forward by the EU and its member
states, such as proposals for the relocation andresettlement of asylum seekers and refugees,
and whilst countries such as Germany actively
welcomed over a million refugees and migrants
in 2015, Europe’s response has been too slow andinsufficient. As for the relocation and resettlement
schemes, these have not been mandatory andstates have mostly refused to participate. As of
3 November 2015, 14 member states had made2284 places available out of the 160 000 European
relocation pledge and only 86 people had effectively
been relocated from Italy. As winter sets in, thehealth and lives of thousands of women, children
and men are more than ever at risk, and the EU’s
policies and actions are all the more inadequate.
This report tells the stories of men, women,children, the elderly, the sick and the disabled,
travelling alone or with their family, fleeing
war, persecution or extreme poverty andseeking refuge and a better life in Europe;
people who were left with no other choicethan to run the obstacle course to Europe.
This report highlights how the EU’s response
so far has not only failed to respond to theurgent humanitarian and medical needsof these vulnerable populations, but has
actively contributed to the worsening of theirsituation, with a sometimes tragic impact on
their health and their lives. This report shows
Europe cannot continue to count on the deadly
sea crossing, fences and poor reception
conditions to act as a ‘filter of deterrence’. The
current narrative and policies cannot hold.
As instability continues to rage across Syria,
Libya, Iraq and Afghanistan, the EU must once
and for all acknowledge the human cost of
its policies and shift its response to provide
assistance, protection and adequate reception
to refugees and migrants desperately seeking
its protection and assistance.

© Alex Yallop / MSF|8

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The European Union’s
asylum framework and policies© Francesco Zizola / Noor

Throughout 2015, the EU’s response to the increased flow of refugees and migrants arriving at
its shores has been framed by the existing general framework of the Common European Asylum
System, and by additional agreements and plans developed mainly from May 2015. As detailed
below, these have predominantly focused on blocking the flow of arrivals rather than addressing thehumanitarian and protection needs of refugees and migrants arriving in Europe.

A General Framework
for Asylum in Europe :the Common European
Asylum System

Developments in 2015 :The European Agenda
on Migration andits implementation

The Common European Asylum System (CEAS)2
was initiated in 1999 by the European Council
with the aim of setting up common rules toensure that asylum seekers are treated equallyin an open and fair system – wherever they
apply. Since then, several legislative measures
harmonising common minimum standards for
asylum have been adopted.

Faced in 2015 with a growing number of people
seeking safety and protection in Europe, EU
institutions adopted a number of plans andpolicies. In May 2015, the European Commission
presented its new European Agenda on
Migration, putting forward immediate responses
and longer-term policy changes for the so-called‘emergency situation’ at its borders3.

The CEAS is made up of five key instruments : theQualification Directive, the Asylum Procedure
Directive, the Reception Conditions Directive,
the Dublin III Regulation and the EURODAC
Regulation.

|10© Alessandro Penso

The Dublin Regulation is of particular importancewhen looking at the movement of asylum seekers,
as it establishes criteria identifying which
member state is responsible for the examinationof an asylum claim, usually the country of firstentry. This regulation is therefore often used
to send asylum seekers travelling through anumber of countries back to the country of firstarrival for their asylum request to be examinedand settled.

The European Agenda on Migration as defined by the European
Commission and adopted in May 2015
Emergency measures• The budget for Frontex Poseidon (Greece) and Triton (Italy) joint operations was provided an additional€26,8 million for 2015-2016 and the area of operation of Triton was extended to 138 nautical miles
southward of Sicily’s coasts.
• The new concept of ‘hotspots’ was created to swiftly identify, register and fingerprint migrants
and refugees arriving in frontline member states and coordinate relocations or returns. It involves
the cooperation of the European Asylum Support Office (EASO), the EU Border Agency (Frontex),
the EU Police Cooperation Agency (Europol) and EU Judicial Cooperation Agency (Eurojust) withthe authorities of the frontline member state.
•  On 22 June, Common Security and Defence Policy (CDSP) operation “EUNAVFORMED-Sophia”
was launched in the Mediterranean Sea. The aim of this military operation is to “undertake
systematic efforts to identify, capture and dispose of vessels as well as enabling assets used orsuspected of being used by migrant smugglers or traffickers”.
• A commitment to relocation (160.000 asylum-seekers) and resettlement (20.000 refugees) ofpeople in need of international protection.
Long-term strategy• Reducing the incentives for irregular migration• Saving lives and securing the external borders• Developing a strong asylum policy (including through the full implementation of the Common
European Asylum System – CEAS)• Defining a new policy on legal migration

Two implementations packages, on 27 May
and 9 September 20154, as well as several
exceptional summits and ministerial meetings
have been organised since, aimed at adoptingsome of the agenda items on migration andother key measures. A meeting of EU Heads ofState on 25 October 2015 on the Western Balkan
Migration Route also agreed on a 17 point
plan of action, focusing on better coordination
between countries, the strengthening of bordermanagement to “slow down the flow”, improved
shelter and tackling smuggling and trafficking5.
With regards to relocation and resettlement,
more concrete proposals were made in July
2015, when the Justice and Home Affairs Council
agreed to resettle 22,504 displaced persons
in clear need of international protection fromoutside the EU6. On 14 and 22 September 2015,
the Extraordinary Justice and Home Affairs
Council and the Extraordinary Home Affairs
Council agreed on the relocation of 160,000
asylum seekers from Italy and Greece to otherEU member states7.
Another area that has been prioritised in recent
months has been returns. On 9 September
2015, the EU Action Plan on Return was put
forward in order to increase the capacity of themember states to return ‘irregular migrants’.
Further proposals have included the creationof a dedicated return office within Frontex
before the end of the year that would “havethe right to organise joint return operations on
its own initiatives, to promote acceptance bythird countries of an improved return laissezpasser for return purposes, to further increase
incentives for third countries and to commit
to returning 400,000 failed asylum seekers”8.
In December, this idea was reinforced in theEuropean Commission’s proposal to create a
new European Border and Coast Guard agency
replacing FRONTEX by a more autonomous andefficient body9.
In terms of funding, the EU and its member
states have focused on providing resources
to three funds, the Syria Trust Fund10, theEmergency Trust Fund11 and the Refugee Facility
for Turkey12 as well as resourcing the WFP,UNHCR and a number of other programmes.
ECHO’s humanitarian aid budget of €324
million in 2015 also includes support for Syria
and refugees in Lebanon, Jordan, Turkey, Iraq

and some Western Balkan countries since July
2015. It cannot however fund the humanitarian
response in key European affected countries,
most notably Greece.
Finally, two diplomatic initiatives involving
EU member states are important to highlight.
First, is the Valletta Conference on Migrationof 11-12 November 2015, attended by EU and
African States concerned by migration andaimed primarily at addressing the root causesof migration in departure countries, tackling
the smuggling and trafficking of migrants
and increasing cooperation on return and readmission13. Second, is the EU-Turkey Joint
Action Plan. In exchange for a European
commitment to a €3 billion Fund to address
the humanitarian situation in Turkey and thepossibility of faster accession to EU membershipstatus, Turkey committed to increased efforts
to stem the flow of migrants across its territory
to Europe and cooperate on the re-admission ofirregular migrants14.
While some new and positive measures havebeen put forward by the EU and its member
states, such as proposals for relocationfrom Italy and Greece and resettlement ofasylum seekers and refugees, much of their
response to date has been largely insufficientand driven by a border-control agenda andthe willingness to stem the flow of arrivals
in Europe, rather than addressing the urgent
needs for assistance and protection of people
fleeing to Europe. Indeed, the objectives of
Frontex’ operations Triton and Poseidon andof operation EUNAVFOR’s are to strengthen
border controls and disrupt smuggling
networks, rather than saving lives at sea oroffering safe and legal passage for people
to seek safety and protection in Europe15.
Other priorities, including voluntary andforced return and funding the humanitarian
response in areas of departure, fail toaddress the complex reasons for people’s
flight ; fail to respond to people’s urgent needfor assistance and protection in Europe; andfail to offer people safe and legal ways toseek the assistance and protection they sodesperately need.

© Alex Yallop / MSF

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73

ON THE MOVE

74

75

76

77

78

68

67

BANDIT

79

80

ASYLUM

81

HUNGARY
Roll the dice again
72

No opportunities

BANDIT

71

Smuggler

Harsh weather
70

69

ON THE MOVE

Closed border

Skip your turn once

BANDIT

66

65

64

The Obstacle Course
to Europe

SERBIA
Closed border

Smuggler

Skip your turn once
55

56

57

Closed border

Roll the dice again
58

59

ON THE MOVE

60

Skip your turn once
61

DETENTION

62

63

Step 1 : Flight

MACEDONIANo opportunities

Little assistance
ON THE MOVE

54

Closed border
53

52

Frost bite

Roll the dice again
51

50

49

Smuggler

Skip your turn twice
48

47

43

44

46

ITALY
Closed border

Roll the dice again
DETENTION

37

38

Fake documents
39

YOU DROWNED40

YOU HAVE BEEN
RESCUEDNo opportunities

Little assistance41

42

Smuggler

GREECE
Leave the game

Smuggler

Skip your turn twice
36

35

ON THE MOVE

34

Go to Italy
33

DETENTION

45

A first important point is that an estimated 85% of the people that have arrived in Europe so far
this year come from refugee-producing countries. About half of them come from Syria, 20% fromAfghanistan, with others fleeing Iraq, Eritrea and war-torn countries including Somalia and Sudan.

You made it
to Europe

Closed border
32

DETENTION

Skip your turn twice
31

30

29

28

LIBYA
Little assistance

Violence
19

21

22

Smuggler

Skip your turn twice

Closed border

Roll the dice again
20

23

24

25

ON THE MOVE

Little assistance
26

27

EGYPT
Fake documents

No opportunities
18

ON THE MOVE

17

Smuggler
16

Closed border15

No opportunities

Roll the dice again

14

13

5

6

12

11

ON THE MOVE

Little assistance1

Fake documents

Closed border

Roll the dice again
2

3

4

DETENTION

Little assistance7

Man from Syria with his wife and six year old son,on board the MSF Bourbon Argos search andrescue vessel

9“Before the war, we had a good life.
But during the war I have seen awful
things. Disaster. That’s all I can say. I
have suffered beatings and torture. For
almost seven months, the army kept
us in isolation without food and contact
with other people. I saw children dying
from hunger. I saw people dying because
they could not receive their medication.”Start here

LEBANONWar

Checkpoint

THIS IS NOT A GAME:The Life and Death
Obstacle Course to Europe
Syria has been consumed by war since 2011. At
more than 4 million, Syrians today are the world’s
second largest refugee community. To escapedeath, detention, and misery, they have to risk
their lives in a long and dangerous path to safety
and asylum. It is the ultimate life and death obstacle course.

Violence

No assistance

Skip your turn twice

MSF runs medical activities in Syria, its neighboring countries, and Europe providing health services
and assistance to vulnerable communities. MSF
works in health, relief, and reception centers in andalong the borders of Tunisia, Italy, Greece, Serbia
and others. MSF-operated search-and-rescueboats in the Mediterranean have rescued more than
15,000 people. Thousands more make the journey
for safety every day.

Closed border

War: Air strikes, barrelbombs, hell canons,
car bombs, chemical
attacks, shelling.

Checkpoint: Militaryor security checkpoint,where one waits topass, stay, or retreat.

Violence: Any acts ofviolence committedby authorities, rebels,
smugglers, bandits.

Detention: Due to lackof documentation or asa form of exploitation.

Transportation:
Planes, trains, buses,
cars, boats and feet
can all be used to reachasylum.

Assistance: Food,medical, and financial
aid provided byinternational and localorganizations, hostcommunities, and othersupport networks.

Closed border: In
countries neighboring
Syria or in Europe,
official borders are
increasingly being
closed restricting the
movement of people
and forcing many tofind alternative routes.

Fake documents:
Fake documents areillegal but they can beobtained with the rightconnection and capital,
allowing the user tocontinue the journey.

Refugee camps:
Located in Syria’s
neighboring countries
of Turkey, Jordan,Iraq, and informaltented settlements in
Lebanon.

No opportunities:
Cultural, linguistic,
political, social,financial, legal barriers
that limit a person’s
ability to nurture afuture in a new place.

Smugglers:Exceedingly becoming
more organized inbringing migrants andrefugees to Europe.
Sometimes they charge
thousands of dollars,
other times they resort
to exploitation, violenceor blackmail.

Drowning: Thousands
have drowned in the
Mediterranean as
they attempt to reach
Europe. The boats
either capsize from theweight, massive waves,or simply sunk bysmugglers

Rescued: Rescue
by coastguards,
fishermen, or MSF andother NGO searchand-rescue operations.
Some modest aid isprovided before thejourney continues.

Bandits: Thieves or
pirates who target
refugees during theodyssey across sea
and land, commonly
demanding money
before allowing thejourney to continue.

Harsh weather:
From frost bites toheat strokes, harshweather conditions
are a major obstacle
to overcome for
migrants and refugees
as they move throughmedley of geographic
environments.

Asylum: Safe-zones inwhich the migrants andrefugees finally receive
official documents andare allowed shelter,
proper aid and relief
services, and areprovided with ways tostart a new life.

This is not a game.

|14

Roll the dice again
8

SYRIA

“When we were on our way, we went
through a tragedy worse than the war
itself, that of being a refugee : that ofgoing through dangerous stages and not
finding a country to welcome you.”

10

TURKEY
Refugee camp

In 2015, 1,008,616 people fled to Europe, fleeing their home countries and seeking safety and a better
life16. Whilst states have been quick to categorise people arriving on their territory as “irregular” or“economic migrants” on the one hand and “refugees” on the other, the reality of this mixed flow is far
more complex.

29 year old man from Syria, on board the MSF
Bourbon Argos search and rescue vessel“I never thought of leaving my country,
or fleeing to Europe. There is no better
place than home but we had no choice.”
Palestinian-Syrian man with his wife and their youngson, on board the MSF Bourbon Argos search andrescue vessel“In Afghanistan I was running apharmacy and teaching at a local school.
One day, some of the men in the village
came to me, accusing me of teaching
Christian ideas to the children. They said,‘You’re not a true Muslim, very soon you
will be beheaded’. Then, at the sametime, I discovered that everything in mypharmacy had been smashed to pieces
and that my father had disappeared
without any explanation. It’s now about
three months since we last heard fromhim, and I don’t know if he is dead or
alive. For this reason I decided to escapefrom Afghanistan, while hiding my family
in another part of the country.”
26 year-old Afghani man, Subotica, Serbia“I have been travelling for about sevenmonths. There are so many problems
in Eritrea, especially the government
policies. You need to serve in the army
for a very long period with no salary.
How are you supposed to eat? Also you
are forced to do work linked to what you
studied. There was no work for me so I

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was put in jail for no reason. I was there
for months, and did not know how long
I would be in prison, so I escaped mycountry in a lot of fear. I have a big family
and my mother is sick so I have to finda way to take care of them. The militarycame to my family when I had escapedand threatened that they all would be
put in prison if they did not respond, orgive them money. As a human being you
are supposed to have rights. In Eritrea
you have none.”
25 year old Eritrean man, on board the MY Phoenix
search and rescue vessel, May 2015

A second important point is that people’s
reasons for wanting to reach Europe arecomplex and their need for protection cannot beassumed based exclusively on their countriesof origin. People’s individual stories, theirvulnerabilities and possible persecution cannot
be understood without a proper assessment of
their unique situation. In addition, some people
who did not have specific protection claims
on leaving their country have since become inneed of protection because of the exploitationand violence they suffered during their journey.
It is therefore crucial that all people seeking
asylum have the right and the opportunity to do
so without discrimination.
This is most certainly the case in Libya where
many asylum seekers and migrants spend long
periods of time, either earning money or waiting
for a break in the weather before braving theseas to Europe. Aboard MSF’s three search andrescue vessels our teams have treated patientswith physical signs of mistreatment during theirtransit in Libya and heard hundreds of stories of
exploitation, torture and rape. Of 125 interviews
conducted by MSF teams in October 2015,
92% of people reported having been the direct
victims of violence in Libya, with nearly 100%reporting having witnessed intentional violence
perpetrated against other asylum seekers andmigrants. Specific accounts include witnessing
beatings, murders, and sexual violence. Close
to half of the people interviewed reported having
been taken against their will and held in shortor long-term detention in formal or informal
centres in Libya, some of them multiple times.

|16

As result of the bad living conditions approximately
one-third of the people assisted by Bourbon
Argos were suffering from scabies, a skin disease
related to overcrowding and unsanitary living
conditions.

Step 2 : Crossing the sea“We come from Nigeria but we lived
in Libya for four years where we had
a normal life, working and living all
together. One day we (the family) were
inside the house and some guys came inwith a gun, they threatened us and they
took my husband, they tried to kill me.
In the end, they left me and my children,
but we couldn’t find peace there. We
had to hide. We were hiding all the time
and we couldn’t come out. The guys
came back and we were scared. We had
to move away. We went to the shore
because we needed to get to the boats. I
have my children and I had to save them.
I knew if I could leave, I would havepeace. That’s why I took my children and
we ran away, joining the boats.”

sid

belgradpresevo
idomeniromelesbosathenssicilySAMOS

dodecaneseislands
bourbonarogs
zarzisMY Phoenix

Dignity I

Nigerian woman with her four children, on board the
Bourbon Argos search and rescue vessel, August 2015

“I stayed three months in Tripoli. I have
no words to describe my life there. It’s
the worst place in the world. They treated
us like animals. They separated womenfrom men and every day they took one of
us to quench their lust. Who wants to stayin Libya under these conditions? I don’t
want to be abused again! So we had nochoice. It’s true, we knew that we could
die at sea, but it was our choice.”
Woman from Eritrea, on board the Bourbon Argos
search and rescue vessel, July 2015

Far from straightforward, people’s reasonsfor fleeing are very complex and cannot be
determined by their nationality alone. The
legal pathways enabling them to find safety,
protection, and respect for their fundamental
rights are being cut off, leaving with them little
choice but to take dangerous routes, putting
themselves at risk of further danger and abuse.

msf project location
rescue operation
search and rescue boat
migration route“European countries […] have expressed sympathy
and willingness to receive [Syrians] as refugees
of war, but what kind of reception and on what
conditions? They are willing to take us in, yet we are
not allowed to go on planes to reach them, we are notallowed to reach them by sea, or even land, in a legal
way, so what then? The message is crystal clear;
we basically have to go through hell and face deathin order to get there... […] The question is whether
we’ll get there or end up being buried at sea – it all
depends on luck.”
Syrian woman and mother of four children, in a letter addressed to
MSF in Greece, February 2014.

17|

A. The perilous sea journey
Taking advantage of the fact that migrants andrefugees cannot use safe and legal routes to enter
Europe17, ruthless and elaborate smuggling
networks have developed in countries including
Libya and Turkey. Since refugees and migrants
most often cannot return home because theirlives would be at risk or because they do nothave travel documents, their only option left
is to put their lives at risk on an overcrowded
boat in the Mediterranean Sea, hoping they will
make it to the other side.
Of the more than 1 million refugees andmigrants arriving in Europe by sea in 201518,
the majority travelled through the eastern
Mediterranean route from Turkey to Greece.
Between 1 January and 31 December 2015,
851,319 people arrived in Greece by sea. In
August and September 2015, an average of
4,000 people were arriving on the Greek islands
every day19. This increased further in October
2015, with the average number of daily arrivals
reaching 6,00020, of which 20% were children
and 14% women21.The month of October 2015
accounted for 33% of the total arrivals in 2015.22
The central Mediterranean route, from North
Africa (most often Libya) to Italy, was the second
most common migratory route for reaching
Europe by sea in 2015. Taken mainly by people
from Eritrea, Syria, Somalia and other subSaharan African countries, it is considered themost dangerous23 route. As of 31 December
2015, the UNHCR estimated that 153,600 people
had arrived in Italy by sea in 201524.

© Francesco Zizola|18“We came down to the water. We were
wearing heavy winter clothes. I’m rather
a good swimmer but my wife isn’t. And
my son is only a year and a half old. We
grabbed a lifebuoy and kept swimming.
Our woollen and leather clothes were
getting heavier and we got tired. I started
to scream. After a long while, some young
boys came back to help us out. It wasn’t
far to the shore – some 150 metres – but
we could have easily drowned with theweight. We were in the water for an hour.
That’s one hour I will remember the restof my life. Imagine how difficult it is tohave your son in your arms and not beable to carry him anymore. I was on theedge of letting both of us go deep down.
Those were terrible moments that I can’t
describe. I still cry when I remember
what happened.”
Syrian man with his wife and their young son
aboard the Bourbon Argos search and rescue
vessel, August 2015

As more people have taken to the sea the numberof deaths continues to increase. In 2015, 3,771
people were registered as having died at sea,
which surpasses the previous record 3,400 lives
lost at sea in the year 2014.
In late 2014, the EU and Italy decided to discontinue
Mare Nostrum, a large rescue-at-sea operation
led by the Italian navy in the Mediterranean that
rescued over 170,000 lives. EU efforts wereinstead diverted towards reinforcing the Frontex
operations Triton and Poseidon, which are mainly
aimed at strengthened border management (seefootnotes 9 and 10).
Boat crossings began rising from March 2015,
and 1,308 people died or went missing at sea
in the single month of April 201525. Faced withthis growing number of people attempting thedangerous sea crossing, and with a clear lack ofsearch and rescue (SAR) resources at sea, MSF
decided that preventing thousands of people
from drowning had become a humanitarian
imperative. Within six weeks, it was operating
three search and rescue vessels in the
Mediterranean Sea.

MSF Search and Rescue
Operations in the
Mediterranean Sea

MSF and Greenpeace
Sea-assistance operationsin the Aegean Sea

1. The MY Phoenix : run jointly with the
Migrant Offshore Aid Station (MOAS), theMY Phoenix was in operation from 2 May
until 22 September 2015. On board were
six MSF staff working in collaboration
with MOAS’ specialist and experienced
SAR crew. The three person MSF
medical team had the capacity to provide
lifesaving emergency medical care aswell as primary health care and could
refer cases in need of hospitalisation to
mainland Italy by helicopter.

On 29 November 2015, MSF in collaboration
with Greenpeace, launched assistanceactivities to boats in distress in the AegeanSea, in the waters between Turkey and
Greece, off the Greek island of Lesvos.
Despite deteriorating weather conditions,
up to 150,000 people crossed the sea fromthe Turkish coast to the Greek Islands inNovember 2015 alone, with 65% of thoselanding in Lesbos. Between September
and November, more than 320 people,
mainly children, have lost their lives in the
Aegean Sea whilst attempting to reach asafe haven in Europe .

2. The Bourbon Argos : Operational between
9 May and 31 December 2015, the Bourbon
Argos could carry 500 people and had crewof 26 SAR specialists and medical staff.
Several containers house activities on
deck, including emergency, consultation,
an observation rooms, sanitary facilities, astock room and a morgue.
3 The Dignity I : Operational between 13
June and 13 November 2015, the Dignity
1had a capacity of 350 people and a crewof 18 medical staff and SAR experts.
The hospital on board included eighthospital beds, a small clinic equippedwith essential medicines and a waitingarea. Medical services provided included
antenatal care to pregnant women andsexual and reproductive health services.
Between 2 May and 31 December 2015, MSF
teams aboard the three vessels rescued
20,129 people in the Mediterranean Sea,
about a quarter of whom were women andchildren. Of the 123 boats in distress thatMSF teams assisted, 95 were inflatableand 28 were wooden. On 31 December
2015, the last MSF SAR vessel still at sea,
the Bourbon Argos, stopped its activities
in order to redirect MSF resources towhere they are most needed in departurecountries, in transit locations and alongother well-worn routes into Europe,
including the Eastern Mediterraneanroute, through the Aegean Sea…

© Anna Surinyach

Between 7 and 28 December 2015, 6,055
people were assisted as part of 143
interventions –people 455 were directly
rescued and 5600 people were guided
or towed to safety. MSF medical teams
at landing point treated 96 people in thefirst 5 weeks of activities, of which 30 werereferred to hospital for further assistance,
mainly for trauma.

MSF training activities
in Tunisia
MSF has also been working in Tunisia tohelp strengthen the capacity of Libyan andTunisian authorities and NGOs to cope withemergency situations at sea. In the coastal
town of Zarzis in Tunisia, our teams havebeen organising training in dead-bodymanagement for fishermen from Zarzis,
Ben Gardane and Ras Ajdir as well as forNGOs (including the Libyan Red Crescent)26.
Civil Protection authorities and Libyan
and Tunisian coastguards have also been
trained and MSF has provided fishermen
and local authorities with rescue equipment
including first aid kits, protective material,
clothing, life vests and body bags.

19|© Francesco Zizola

People who embark on the journey to Europe face
many dangers. These include the risk of drowning
following boat capsizes or during rescues,
which are always very delicate operations27. The
crossing from Libya to Italy takes an averageof 30 to 74 hours and the crossing from Turkey
to Greece takes 45 minutes to a few hours.
Shipwrecks are common, especially if weather
conditions are rough. Vessels are mainly small
inflatable Zodiacs or old, wooden fishing boats
and are often unseaworthy and overcrowded.
Migrants and refugees are frequently left alone
onboard with no experience of the sea, nonavigation equipment and meagre fuel. It is little
wonder the vessels often get in to trouble soonafter their departure.

aid to survivors of shipwrecks. Of the 1,559
patients MSF mental health teams supported
individually or through group sessions between
June and December 2015 in Italy and Greece,
28% presented symptoms of anxiety, 20% had
symptoms of depression and 7% had symptomsof post-traumatic stress disorder.

A boat containing approximately 650 people
is rescued in the Mediterranean Sea by
the Bourbon Argos.

On 29 October, MSF provided support to a
woman and her three daughters after theirboat capsized near the island of Farmakonisi.
The MSF Field coordinator in the Dodecaneseislands explains :“They were desperate; wehelped them change their wet clothes and gavethem blankets. The woman was brought to the
Hospital of Leros and we provided psychologicalsupport to the daughters. The husband arrived
with a second trip of the boat bringing people
from Farmakonisi to Leros and they werereunited.” The following day, after a shipwreck
off the island of Kalymnos, our psychologist
conducted sessions with 10 survivors, including
a 27 year old Iraqi man who had lost his disabledbrother, a 32 year old Syrian man who had lost
his three children and a 35 year old Syrian man
who had lost his wife, son and daughter.

“No one knew how to drive the boat, wewere all saying ‘we will die, we will die!’A lot of water entered the boat. We all
moved on one side and the boat almost
turned over! We were all in shock
and we were all crying. I was thinking‘it does not matter if I die’, but I wasworried about the two little girls” (onefour year old and one seven year old)
17 year old girl from Somalia, aboard the MSF
search and rescue vessel Dignity I.

On 5 August 2015, after a wooden boat carrying
between 600 and 700 people capsized close to the
Libyan shore, the MSF search and rescue vessel
Dignity I was called to assist. Only 300 people
are believed to have survived the shipwreck.
Survivors explained with horror how the boat
was mainly filled with families and that most of
the people missing were women and children
who did not know how to swim.

“It was a horrific sight, people
desperately clinging to lifebelts, boats
and anything they could to fight for theirlives, amidst people drowning, and those
who had already died.”
MSF project coordinator on board the Dignity I,
August 2015

On 28 October 2015, 43 people, including
20 children were reported dead after a boat
capsized near the Greek Island of Lesbos.
That same day, 19 people went missing after
a boat sank off the island of Kalymnos in the
Dodecanese. Four people went missing off theisland of Samos and three people in an incident
off the island of Agathonisi.
On 16 December 2015, a wooden boat carrying
around 85 people capsized off the northernshores of Lesbos. When the MSF-Greenpeaceassistance boats arrived at the scene, theteam quickly began rescuing as many people
as possible, handing out floating devices tohelp those still in the cold water. Survivors
were transferred to vessels operated by othervolunteers. In all, 83 people were rescued andtransferred to the nearby towns of Molyvos
and Petra. Many were in need of resuscitation
or were treated for hypothermia by MSF
teams at the arrival points, and three patientswere referred by MSF to a local hospital for
hypothermia, among them a child. At least two
people – an 80 year old man and a nine monthold child – drowned.

Medical teams on board search and rescue
vessels have time and again witnessed theterrible, precarious and often life-threatening
conditions experienced by people in transit
countries such as Libya and on board the flimsy
vessels in which they make their sea journeys.
With scant food, water and blankets on board,passengers, especially the most vulnerable,
face dying of dehydration, hypothermia or
exhaustion28. Of the 4,443 patients treated by the
Bourbon Argos medical team in 2015, aroundhalf were suffering from minor ailments and aconsiderable number suffered from more serious
ailments, including violent trauma (39 patients,
or 1%), scabies (1236 patients, 28%), chemicalburns (69 patients, 2%), trauma (72 patients,4%), dehydration (10 patients) and more recently
hypothermia (two patients in Bourbon Argos andsix patients in the Aegean SAR).

In a number of rescue operations, MSF arrived
too late to save some of the people in distress.
On 27 July, the Dignity I attended a wooden
boat in distress with 312 people on board.
Teams found the bodies of 14 people locked in
the engine room who had died of asphyxia. One
disabled man on the upper deck died just before
the rescue team arrived. On 23 August, a 12 year
old Somali boy rescued on a boat coming from
Libya was admitted to the on-board clinic on the
MSF vessel Dignity I. He was suffering from achronic disease and had been beaten in Libya.
He sadly passed away from a sudden cardiac
attack before the vessel could dock in Italy.

The impact of people’s experiences and trauma
at home and during the journey on their mental
health is difficult to measure, but also requires
close attention. MSF conducts individual andgroup sessions with people arriving in theislands, and also provides psychological first© Alessandro Penso

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21|

Similar stories were reported in the media andorganisations working on the ground throughout
the summer and early autumn. They describedattacks in which armed assailants deliberately
disabled boats transporting refugees by damaging
or removing the engines or the fuel, or puncturing

MSF and Greenpeace conduct joint sea
operations to provide assistance to boats
in distress off the coast of Lesbos.

the hulls of inflatable boats. In some accounts,
the boats were towed back to Turkish waters29.
In November 2015, our medical teams in Leros
treated patients who had just survived an attackat sea :“We left the Turkish coast with 45 people on board (…) After a while a big motorised
grey boat approached us (…) It was armed with a heavy weapon and had a Greek flagon it (…) I saw three men (…) wearing dark blue uniforms with the Greek flag. We
showed them that we had children on board and that we needed support (…) Once
close (…) they took a long metallic stick with a hook and (…) hit the (…) [anterior buoy].
The first two punches came fast and perforated the front of our boat . The water
quickly started to enter our boat. Children and women were shouting. We started
frantically to use our hands to bail out the water from the boat. There was total panic
on board. After a while (…)we saw another big metallic boat. This one was orange,(…) [with] five men inside, wearing the same dark blue uniforms with clear blue flags.
We shouted and asked for their help... we saw the men on board laughing loudly.(…)
We watched this boat returning to the island, Farmakonisi. The people in my group
say they are sure that it was the same boat that later brought us from the island
Farmakonisi to here, Leros. The panic on board is indescribable (…) We all saw deathcoming. We had children on board, how can somebody do that to children? We fled
our country because our lives were in danger there. The first thing happening to us
entering into Europe is men in uniform trying to kill us.‘’© Will Rose / Greenpeace

B.	Aggravated factors for distressat sea - targeted violence at sea
and on shore
Left to fend for themselves on unseaworthyboats, refugees and migrants don’t only face
the dangers of the sea, but at times also faceattacks during the crossing.
In July 2015, our teams in Lesvos and Kos began
to be approached by refugees who wanted
to share their troubling stories of violence
at sea involving unidentified masked groups
either robbing them or throwing their personal
belongings overboard. Some people recounted
bigger boats approaching dinghies and trying topierce and sink them with long perches. Others
described boats seemingly belonging to the
Greek Coast Guard sailing by without coming
to their rescue. Our teams continue to receive
such reports from those arriving on the Greek
islands.

‘We were attacked in between Turkey
and the island (Farmakonisi), by 3 menin uniforms on board of a large metallic
grey boat. I saw 3 male adults on board,
wearing dark blue naval uniforms
with a greek flag on the shoulder. We
got closer to them, showed them ourchildren to get some support from them.
I cannot forget what happened. Once wegot close to them they used the harpoon
to brutally punch our boat in front. They
did 2 holes and it was completely the
panic on our board. They wanted to killus. I don’t want it to happen again toother refugees. Before the attack […],
the sea was quiet and we were not indanger. Our lives and lives of my own
nephew would not have been in danger if
the men would not have attacked us.’

35 year old Afghan man, Leros, Greece, November 2015

Refugees prior to embarkation
on board the Bourbon Argos.

Syrian man, Kos, Greece© Christophe Stramba-Badiali / Haytham Pictures

|22

23|

MSF teams treated two children that survived theattack described above. One eight year old boy
came to the MSF clinic with his father. He told ourdoctors “Since we have been in the water I feelvery sad. I don’t know why but I feel very sad”.
Fighting back his tears, his father explained that
his son had difficulty sleeping since the attack,waking up with nightmares, as well as sufferingfrom bronchitis.
Another child, six years old, came to our clinicwith his mother. Having fled from the war in
Afghanistan, she explained :“My son was completely in the water,
there was water all in the boat after theattack. But I managed so that his head
didn’t enter the water until we reached
the island Farmakonisi. He was in myarms and I was holding him so tight. I
was afraid. His whole body was black.
His lips were completely blue. It was amiracle nobody died.‘’MSF teams carrying out mental health activities
on shore report that patients who face incidents
of violence at sea have already been throughdistressing experiences related to war, violenceand persecution on land. Facing ill-treatment
or violence during this journey by boat serves toaggravate the psychosocial risk they are subject
to, and often leads to intense distress, andsymptoms of acute anxiety, hopelessness, fear
and insecurity.
The involvement of the Greek Coast Guards inthese attacks has been denied publically by the
Greek authorities, but no thorough investigations
are known to have taken place. Given Frontex’s
support to the Greek Coast Guards, it has a
key role in following up on these claims with
the Greek authorities so as not to render theEuropean Union complicit of such potential
crimes.
Abuses have also been reported on the Greek
military island of Farmakonisi by patients wetreated in Leros and other Dodecanese Islands.
Out of 343 patients supported for traumatic
events by our medical and mental healthteams in Greece in 2015, 81 (24%) reported thatincidents had taken place on Farmakonisi.

|24“On the military island they made us kneel,waiting in the sun for many hours. You can
see that we are burnt from the sun. They
had tied our hands and were slapping us
without any reason. Also, when we were
sleeping they came inside the room andbeat us with iron sticks. They took mymobile battery and then they asked me for
20 euros to get it back.”

Our patients tell us they are aware of
the risks involved in the dangerous sea
crossing, but that they are ready to die.
Those who have life jackets sometimes
write names of relatives to be contacted
in case they drown : “When I ask people
why they risk their lives in this way, I
get the same answer every time : ‘there
is no alternative.’ These people know
the dangers but they take the gamble
anyway. They tell us that they would
rather drown seeking safety and freedom
than stay in their homelands or in Libya
where their lives are not worth living.”

31 year-old Syrian man, Leros, Greece“We were on the military island. A
soldier was shouting in English ‘I don’tcare about the laws – For me the laws
do not exist – Here there is only one law– The army law.”

MSF Emergency Coordinator on board of the MY
Phoenix

40 year-old Iraqi man, Leros, Greece“We were asked to switch off our mobiles
and put them in a bag with our money.
I put my wallet inside. I had 1200 euros
to continue my trip. When they returned
our stuff, my money was missing. They
had left only the Turkish Liras inside
my wallet. I don’t have money. I had left
some money with my wife and children
to manage until the time I arrive to mydestination. A soldier asked me to standup and start running. I explained that I
couldn’t do that as I have a problem withmy leg. He kicked me on the same spotthat I had been injured. You can see thatmy leg is swollen.”

Although proactive and large scale SAR
operations are necessary to save lives indanger at sea, they are not the solution toforced migration by boat. They will never fully
prevent refugees and migrants from dying atsea, and they will not prevent attacks at sea.
It is the lack of safe and legal alternatives toapply for asylum or migrate to Europe thatforces people to resort to smugglers and risk
their lives on such dangerous and uncertain
journeys. Safe alternatives to the dangerous
sea crossings exist, including land crossings
between Turkey and Greece, as well between
Turkey and Bulgaria. But today, these safe andlegal alternatives continue to be dangerously
overlooked by member states of the European
Union who have instead invested their resourcesand efforts in blocking the flow of asylum
seekers and migrants and launching military
operations against the smuggling industry in
Libya, while turning a blind eye to the violence
plaguing its own borders.

© WIll Rose

27 year-old Iraqi man, Leros, Greece

MSF medical teams treating patients that
arrived on the island of Farmakonisi have been
shocked by the particularly poor health conditionand signs of violence. Indeed, many of thesepatients show signs of beatings and present withsymptoms of physical exhaustion. In Octoberand November 2015, our medical teams inLeros treated 107 diabetic patients arriving from
Farmakonisi with high blood sugar levels andwho did not receive medical attention on theisland. Our psychologists have also noted thehigh level of trauma exhibited by these patients.

MSF and Greenpeace conduct joint sea
operations to provide assistance to boats
in distress off the coast of Lesbos.

25|

Step 3 : Arriving in Greece and Italy Inadequate reception conditions for asylum
seekers in Greece and Italy
For those who have survived the sea journey
to Europe’s shores, new challenges lie ahead
including finding a safe place to disembark,understanding the registration process andbeing able to find adequate shelter and essential
services. MSF teams have seen many of thepeople rescued smile, raise their hands and kissthe ground when they finally set foot on Europeansoil. Unfortunately, for the majority, the obstacle
course to safety is far from over and many new
dangers await them in Europe.

GreeceIn 2015, Greece became the first entry point
for migrants and refugees attempting to reach
Europe. As of 31 December 2015, 851,319 people
had crossed the Mediterranean and arrived in

Greece, mainly in the ports of Lesvos, Samos,
Chios, Kos and Leros. More than 91% comefrom countries affected by war or generalised
violence (mainly Syria30, but also Afghanistan,Iraq, and Somalia) and over a third are womenand children.
Despite deteriorating weather condition andmost likely due to the perception that European
borders are closing, October 2015 saw thelargest number of people arriving in Greece, withan average of 8,700 people arriving every day in
the Greek islands in the week 15-21 October31.

“I avoid drinking water…in that way I will
not to have to go to the toilet.”A dramatic reception crisis
For years, Greece has been unable to offer
decent reception conditions to asylum seekers.
Only two islands, Lesvos and Samos, havereception facilities in place, although eventhese remain insufficient. Faced, since May
2015, with an increased flow of refugees andmigrants arriving on its shores and waiting
to be registered, existing local capacity was
immediately overwhelmed. Organising thereception of a population, registering the many
vulnerable groups arriving unannounced andonly transiting for a few days is a real challenge.
But the lack of adequate and speedy response
from the authorities has allowed the situation tospiral out of control, and has led to unacceptableliving conditions for these already vulnerable
people. A year into this crisis, despite numerous
visits by EU representatives including theEuropean Commissioner for Migration32, both
the reception infrastructure and the asylum
system in Greece continue to fail to adapt to theneeds of the refugees and migrants.

Syrian Woman in Kos, Greece

The island of Lesvos, where close to 60% of all
migrants and refugees arriving in Greece land,
only had a daily reception capacity of 1,480 people
in October 201534. This was nowhere near enoughto provide shelter for the estimated 5,000 people
who arrived each day and spent up to several
subsequent days on the island. As of October
2015, Syrian families had to register in Kara
Tepe camp, where they usually spent the nightin very basic tents or Ikea pre-fabricated houses,
before leaving the next day for the port of Mitilini
to reach Athens by ferry. Single Syrian men andpeople from other nationalities had to register at
Moria camp, the first Greek ‘hotspot’, where nonSyrians have to wait about three days for theirregistration, with little or no accommodation or
assistance provided. As a result, whole families
and groups were sleeping rough in the vicinity of
the registration camps, with very little protection
from the sun, cold and rain, under trees, orin small tents if they were able to buy one. For
months, humanitarian organisations have beencalling on the Greek authorities to improve the  reception conditions in Moria site and increase
the shelter capacity on the island.

A comparison of the capacity and needs for reception in the Greek islands as of October 2015

idomeni

Average # daily arrivals in Oct33# Number of reception places

Lesvos :4,400

700 official and 780 by humanitarian actors

Chios

900

110

Kos

800

0 official, 200 by MSF

Leros

400

0 official, 421 by humanitarian actors

Samos

800

250

lesbos

SAMOS

rescue operation“We are staying in a dirty tent. There are no mattresses to sleep on, just cardboard
boxes. There are no blankets, nothing, just dirt. We don’t even want to go near the
toilets. The water is not clean, we cannot wash. For breakfast, we have one piece ofbread shared between three people. One woman arrived today with her two small
babies. Their clothes are all wet, but they don’t have any more clothes. She has been
asking where she can find some milk for her baby, but nobody gives her milk, so shewill have to buy it from somewhere. I can’t believe that I am living in such conditions
with my family. I used to be a teacher and my husband was an accountant. Look at us
now. This is inhumane.”migration route

28 year-old woman from Syria with her husband and their four year old daughter, Kara Tepe camp, Lesvos, Greece35

athensdodecanese islands

msf project location

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On the island Kos, where 200 to 500 people
were arriving every day in October 2015,
there is no reception facility, as the local
authorities continue to oppose the creation of
any organised reception or transit facility on
the island. In the informal camp of Captain
Elias, 500 to 700 people used to sleep on thefloor of a dilapidated old building that MSF
rehabilitated with a capacity of maximum
200 people. Under pressure from the local
authorities, this informal camp was closed andpeople were evicted on 10 September 2015.
In September, MSF created shelter for 200
people behind the police station.

“We have been here for five days. Life
here is very expensive. Hotels as well.
We cannot afford them. That’s why wehave to stay in the streets. But every
day in the streets costs us money. Everyday we have to chase the shadow. Fromthe shops and cafes they push us. (…)
We do not want to stay here, we want toleave. But here every day the situationis getting worse […] We drink waterfrom the water points that are made forthe private yachts. When there is one
running we try to take the opportunity…
There is also one toilet that they open
for one hour per day.”
Syrian man with his wife and five children, Kos,
Greece“People arrive on the Greek islands after
having gone through a lot of hardship. We
have seen children and adults still wet,
who are forced to sleep outdoors. There
are patients with diabetes and there is noprovision of medical screening or special
nutritional requirements. All these
conditions are especially harmful for the
refugees’ health, besides the fact that
it is insulting for their dignity as humanbeings.”MSF Medical Doctor, Dodecanese Islands, Greece

Whilst understandably overwhelmed by thescale of the arrival of refugees and migrants inthe first weeks of May 2015, national and local
authorities subsequently completely failed
to provide for the needs of these vulnerable
populations. What is even more concerning isthat authorities have not only failed to comply
with their obligation to provide adequate
reception, but have also prevented non-stateorganisations from stepping in to providethat assistance. Some of the numerous
administrative obstacles experienced by MSF
teams over the past year include the refusal by
the Kos municipality to allow MSF to put up tents
for emergency shelter in a car park in town, andlocal authorities not allowing MSF teams to put
up tents in a park behind the harbour in Lesvos’port of Mitilini.

On other islands where there are no official
reception centres, thousands of new arrivals
have had no other choice than to settle in publicparks, where they have little or no access towater, shelter, toilets or medical care. With
very little assistance provided, these vulnerable
people have had no access to vulnerability
and medical assessments or referrals for
those most at risk. In addition to these living
conditions, the Greek authorities gradually
withdrew all food provision in the Greek islands
during the summer.

The failings of the Greek authorities are notlimited to the lack of reception, but also include
the failure to provide swift and effective accessto registration procedures and information
regarding asylum procedures and basic services.
Indeed, the administrative registration process
in Greece, which is carried out by the police, ismandatory, extremely heavy, constantly changing
and involves, in some islands, 15 different steps.
Throughout the summer, each Greek island
followed a different registration system.
The lack of swift access to registration; thecomplete absence of information provided by
the police and Frontex; as well as the lack ofadequate crowd control, have repeatedly led tochaotic situations with tear gas and violence
used by the authorities. Humanitarian organisations have been forced to take on the state’s
responsibility of providing crucial information
to the refugees and migrants and in some instances even forced to handle crowd control.

“We were given a piece of paper by
the port police, but since then we havebeen waiting here and have heard
nothing. Nobody tells us anything.
There is no one responsible for giving
us any information, and we don’t knowwhat to do. No authority, no police, noinformation, nothing.”
26 year-old Syrian man with his wife and baby,
Lesvos, Greece

none of the people we talked to hadreceived any information on what wasgoing on, most waited around on thegravel field, too scared to leave to go
and get water or food outside. The twoavailable toilets quickly filled up andbecame unusable.”“Since only three police officers were in
charge of registration on Tuesday, theprocess was extremely slow and somepeople in the crowd, forced to queue
under the sun all day long, started
getting upset. The police, unable tokeep control of the situation they had
created, used tear gas to disperse themthat afternoon and at least one stungrenade in the evening. The situation
inside the stadium quickly degenerated :roughly 2500 people were locked in all
Wednesday. People were fainting at
an alarming rate and urgent referrals
to the local hospital needed to beorganised. All the people I talked to werecompletely lost as to what was going on
and why they were being treated thisway. Their main concern was to try andfind a way to find food and water without
losing their spot in the registration
queue, while not drinking too muchsince there were no toilets. It was a very
shocking couple of days.”
MSF Humanitarian Affairs Officer, Athens, Greece

In Kos, registration descended into chaos on 1012 August 2015.

© Alex Yallop / MSF|28

A failure to provide swift accessto registration and information“On Monday 10 August, the local
authorities on Kos Island began
sweeping operations to push the people
away from the town centre. Syrian
families were told to gather at an open
air stadium and await registration there,
instead of the police station. Over thecourse of the day, the numbers in thisopen-air stadium started to swell. As

During the event, our teams treated seven people
crushed by the crowd and 33 for heat exhaustion
and loss of consciousness. We referred four
patients to the local hospital and received atleast three reports of police violence.

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The health impact of the government’s
failure to provide access to reception
facilities and other essential services
In Greece, the lack of swift registration andadequate reception conditions has put thehealth and safety of refugees and migrants at
risk. For months, our medical teams throughout
Greece have treated the health consequencesof the extremely precarious conditions refugees
and migrants are forced to endure for days36
before their identification and registration iscompleted.
Between June and November 2015, twothirds of the patients seeking care in MSF
clinics in Greece suffered from respiratory
tract infections, skin diseases and trauma –all linked to the dangerous and unhygienic
conditions they were living in. Among women of
reproductive age that attended MSF clinics, 838(13%) were pregnant while 4,360 (14%) werechildren under five years old and 2,233 (7%) of
our patients had a chronic disease, including
diabetes, cardiovascular disease, lung disease,cancer and chronic renal failure requiring
dialysis. With no screening of people’s medical
vulnerabilities on arrival, the system, or rather
lack thereof, further endangers the lives ofrefugees and migrants.

“We have witnessed a lot of pregnant
women and children queuing forseveral days in the mud, soaking wet in
the pouring rain without any protection,some of them only wearing a t-shirt.
People can’t stand up anymore because
their feet are swollen after being
wet for several days. Without theintervention of our medical teams or
volunteers, police don’t allow refugees
to leave the queue to have access tohealth care. Our staff have to look forthe sick and injured in the queues tobe able to redirect them to the clinic.
In addition, the registration process
keeps on being changed, with noinformation shared with the people andhumanitarian organisations. This iscompletely inhumane.”
MSF Project coordinator in Lesvos, Greece

The situation – already worrying over the summer– has only got worse with the rains setting inand winter approaching. MSF medical teams
in Greece saw a 160% increase of respiratory
tract infections between July and October
2015. Patients described how they had fallensick sleeping outside on the bare ground, withno protection from the rain and cold. Between
October and December 2015, our medical
teams in Greece and Serbia treated 19 cases ofhypothermia, 12 of which were in Idomeni, at the
Greek-FYROM border.
The lack of access to information and basic
services such as shelter, food and sanitation
impacts not only people’s physical health, butalso on their general well-being and mental
health. An MSF psychologist working with asylum
seekers and migrants in Greece explains :“Although arrival in Europe would
normally mean having finally escaped
war and violence, people’s situations arestill difficult due to the lack of a proper
reception system. This leaves them
exposed to additional fear, insecurity
and risks such as the non-fulfillment of

their basic needs and limited access tobasic medical care or legal information.
People with previously identified mental
health difficulties are facing the risk of adeterioration of their health due to the lackof a timely identification of needs and theproper referral to medical or other care.”Failing to comply with EU standards of reception, the Greek authorities have focused exclusively on police and registration procedures,
neglecting to put in place an asylum reception
system and failing to respond to the urgent andessential needs of the refugees and migrants –be it for shelter, food or water and sanitation.
These shortcomings, which are of particularconcern given the vulnerable condition of thesepeople, are not only morally and ethically unacceptable, but also violate basic human rights
and EU and Greek legislation37. The treatmentof asylum seekers in Greece was qualified asinhumane and degrading treatment by the European Court of Human Rights in 2011, and at
the beginning of 2015, UNHCR called on EU
member states to suspend Dublin transfers ofasylum seekers to Greece.

A 7 months pregnant asylum
seeker in Serbia© Julie Remy / MSF|30© Georgios Makkas

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MSF medical activities in Greece

Between 17 March and 27 December 2015,
MSF teams provided just over 43 000 medical
consultations to refugees and migrants
in Greece.
Kos
In December 2014, after a four month long emergency intervention on the island of Kos, MSF decided
to withdraw, as we came to the difficult conclusion that given the circumstances in which people wereleft stranded on the island, our medical impact was limited38. MSF returned to the island in March 2015and has been providing primary health care as well as mental health support and information to people
arriving; distributing Non-Food Items (NFIs) and working on sanitation facilities and shelter. At the timeof writing, there is still no state-organised reception on the island.
Between 17 March and 12 December 2015, MSF undertook 8,700 consultations, of which 37% were
women and children; 158 individual mental health sessions and 509 group sessions with 4,242
participants.
Lesvos
MSF began its activities in Lesvos in July 2015, providing medical and mental health care in the Moria
and Kara Tepe registration camps, as well as at the port of Mitilini. Teams also provide temporary
shelter and transport to and from the Mantamados transit point. In November 2015, MSF stepped up
its presence and activities on the northern shore of the island where most of the boats arrive. Medical
teams aboard two ambulances stand ready to provide urgent medical care and refer patients as they
arrive on shore.

© Achilleas Zavallis

Athens
MSF is also present in Athens, where MSF teams started mobile clinics in December 2015. As a resultof, new restrictions on movement imposed at borders, an increasing number of refugees and asylum
seekers are staying in the capital.
In collaboration with the Greek organisations Babel and the Greek Council for Refugees, MSF teamsin Athens are also providing medical and psychological services as well as legal support to refugees,
asylum seekers and undocumented migrants who have been victims of torture. In September 2015, theteam had 136 patients in the program. The most commonly referred types of torture are blunt and headtrauma, threats, and bad detention conditions. Most patients suffer from one or several mental issues
including anxiety, depression, psychosomatic symptoms or symptoms of psychosis. Forty percent ofpatients present symptoms of post-traumatic stress disorder (PTSD).
Greek-FYROM border

Between 28 July and 13 December 2015, MSF carried out 12338 consultations, of which 70% were womenand children; 199 individual mental health sessions and 381 group sessions with 2598 participants.

At the Greek-FYROM border MSF has been present in Idomeni, running mobile clinics, building
shelters, putting in place water and sanitation facilities, and distributing relief items to people whowish to continue their journey to northern Europe through the Western Balkans.

Leros and small Dodecanese Islands

For the period 1 April 2015 – 13 December 2015 MSF undertook 11,833 consultations, of which one
quarter were women and a further quarter were children. From July to December 2015, 230 individual
mental health assessments and 735 group sessions were provided in which 13,357 individuals
participated.

In June 2015, MSF started visiting the islands of Leros, Simi, Tilos and Kalymnos and established apermanent presence on Leros in September, with teams working on shelter, water and sanitation,
distributing NFIs and providing mental health support and primary health care services.
Between 15 June and 12 December 2015, MSF carried out 4676 consultations, of which 68% were womenand children; 69 individual mental health sessions and 268 group sessions with 1552 participants.
Samos
In October 2015, MSF put in place an ‘emergency call’ service, enabling MSF teams to be called whenboats arrived. Medical teams provide first aid to refugees and migrants disembarking and transportthem to the closest town on the island, Vathy.
Between 5 October and 1 November 2015 MSF carried out 645 consultations, of which a third were forchildren under the age of five.

|32

For months, MSF and other organisations have been calling for Greek authorities to improve
reception conditions and assistance to transiting refugees and migrants on its territory. These calls
have fallen on deaf ears, to the detriment of refugees and migrants health, dignity and protection.
Greece’s failure to assist and protect the people reaching its shores is not only due to chronic failuresin its reception system or to a lack of financial resources. It is also due to the lack of a coherent
plan and the national government’s inability to convince local authorities on the islands to improveconditions. Finally, the situation in Greece is also the result of the failure of the European Common
Asylum system and of the EU member states to collectively provide a responsible, functioning andcoherent reception system for asylum seekers.

33|© Francesco Zizola

Italy
In Italy, where sea arrivals are nothing new,the reception system for migrants and asylum
seekers has been put under great strain. In 2014
the number of asylum applications in the country
reached a record 63,45639. This has grown evenmore in 2015. The year 2015 has seen 153,600
people arriving by sea40, predominately madeup of Eritreans, Nigerians, Somalis, Sudaneseand Syrians. The main ports of landing have been
Augusta, Pozzallo, Palermo, Reggio Calabria andLampedusa.
© Francesco Zizola

Inadequate reception conditions and accessto essential servicesromesicilybourbonarogs

MY Phoenix

Dignity I

msf project location
rescue operation
search and rescue boat
migration route|34

Even though Italy is better prepared forreceiving migrants, asylum seekers andrefugees than Greece, with a formal reception
system of 99,09641 places, assistance at theexternal borders and reception conditions
are still largely insufficient and ill-adapted
to the needs of those arriving. Disembarkation
conditions at different landing spots in Italy
are not homogenous, despite the release in2014 of the Contingency Plan for Health in
the context of Migration42, issued by the Sicily
Region. This is due to variations in the levels of
resources made available, and in the presence
and coordination of the different organisations
involved. In some harbours MSF has witnessed
security protocol and procedures that are to
the detriment of an appropriate humanitarian
approach to disembarking refugees.
Capacity at first reception level (Centre of FirstAid and Assistance or CPSA) is problematicdue to the lack of adequate strategic planningnationally, coupled with poor management of
resources. This has resulted in centres facing
overcrowding and offering limited access tolegal advice and healthcare.

One example of the failure of Italian authorities
to meet the reception needs of refugees andmigrants is the reception centre of Pozzallo
CPSA in Sicily. Designated by the EU as oneof the ‘hotspots’, which aims to improveregistration and processing capacity in Italy, it
officially offers 300 places43. The real capacityof the centre, however, is 180 places.
In November 2015, MSF submitted a report to
the Italian Parliamentary Investigative Commission on the Reception System, the Identificationand the Treatment of Migrants, highlighting theinadequate conditions of the centre and the lackof efforts made by local authorities to address
the issues. As detailed in the report, the centre
is often overcrowded. Structural problems have
led to poor hygienic conditions and difficulties inproviding treatment for certain ailments such as
scabies. The lack of space also means that it is
not possible to separate unaccompanied minors
from adults and women from men, and that there
is no designated space to identify vulnerable individuals such as victims of torture, or trafficking
and survivors of other forms of violence. Depending on available places in first reception centres,
people might spend a few days inside the centre,
including vulnerable individuals such as pregnant
women, families, unaccompanied children andpeople with psychological issues.

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“Today, 18 corpses arrived in Pozzallo.
More corpses. Is there anybody
still thinking that people take thedecision lightly to cross half of theworld risking their lives to reach thewonderful Europe? (…) On Friday, inAugusta, we received a child with acentral venous line for chemotherapy.
Last week a paraplegic Eritrean
girl landed in Pozzallo, after having
crossed the desert in a wheelchair.
Some weeks ago a teacher from Ivory
Coast told me he worked in Libya for
two years and wassuddenly forced
to escape because of ‘black-people
hunting’.”
MSF Project Coordinator in Pozzallo, Sicily, Italy.

An additional problem with regards to Pozzalo
CPSA relates to the identification and registration procedures. These procedures should
normally take place only after legal information is provided to asylum seekers arriving in
the centres. As highlighted in the report to theParliamentary Commission, MSF is concernedthat identification procedures are carried out
very quickly, while medical and humanitarian
responses are still taking place, curtailing thenecessary space and time for the individuals
to take some rest and receive all the necessary
legal information. In September and October,
MSF’s teams in Pozzallo witnessed about 100
cases in which rapid identification procedures
were immediately followed by expulsion notices and requests to leave the CPSA. Such cases
included several women, one of them pregnant, two minors and several people in needof or undergoing medical treatment. After thiswas raised with relevant authorities, these
rapid procedures and expulsions, which risked
compromising the adequate assessment ofpeople’s asylum claims, were stopped.
In December 2015, MSF announced the end of
its activities in the Pozzallo CPSA, as conditions
were no longer suitable for the organization towork there.

The inadequacy of the first level reception
capacity is linked to the emergency context inwhich the general reception system structure
was scaled up in 2014, as numbers of asylum
seekers soared. Indeed, 70,918 asylum seekers
are currently hosted in the temporary CAS centres, whereas only 21,814 are hosted insecondary level SPRAR (Protection System for
Refugees and Asylum Seekers) structures.)dedicated to the reception and integrationof refugees. The widespread developmentof CAS44 centres does not reflect a plannedand structured response and remains,
unfortunately, emergency focused.
The absence of a consolidated reception
strategy has led to the current lack of adequate
reception structures (many are located inremote areas and lack basic facilities), as wellas qualified and experienced personnel able torespond to the multiple needs of the asylum
seekers. Essential services that should be
provided in CAS  structures (including primaryand secondary health care, mental health care,and legal and administrative support) are underresourced, under-staffed and lack qualified
cultural mediators and interpreters. Additionally,administrative support for the completion oflegal and administrative formalities is provided
by local and national institutions whose humanresource capacity remains limited, reducing
their capacity to respond to the assistance needsof a growing asylum seeker population.

A worrying lack of access to healthcare for vulnerable populations“I was conducting an information session at the Baobab centre when I noticed
a very young boy who attended the session but stayed to one side for the entire
time. I was struck by his young age and by the fact that he seemed to be alone.
As I approached, he (…) began to speak about his journey. In Egypt he hadalready faced detention. When he was about to embark on a boat to cross theMediterranean he saw an Ethiopian man who did not know how to swim drown infront of everybody with no possibility of helping him. The day after, on the boat hewoke to the screaming of a Syrian woman trying to wake up one of her two little
girls, calling her name and trying to move her. The other little girl was screaming
desperately. He understood that the little girl was dead. The father and other
Syrian men moved the body to a corner of the boat where he could see it (..). He
recalled the desperation of the mother crying while other Syrian women were
trying to comfort her. The boy watched as the little body was wrapped in a sheet
and then thrown in the sea. He told me that, after that and for many days, hewould think about the fishes eating the body of the little girl. This thought cameoften to his mind and he dreamt about it. At the time we talked, his mind was
haunted by two thoughts : the body of the little girl and the concern over the riskof being fingerprinted.”
MSF intercultural mediator and coordinator in the psychological first aid team, Rome, Italy

The reluctance of refugees to remain in Italy in thecurrent reception system leads many of them, inparticular those of Eritrean origin45, to continue
their journey toward northern European countries.
They often arrive from landing ports in Italy (orafter staying a short time in CPSA structures)and remain in the territory for a limited period
while they regroup46 in order to reach their finaldestination. MSF has approached this populationin transit in two informal spots in Rome, atTiburtina train station and at the Baobab centre,
providing them with practical assistance suchas general orientation, information about healthcare rights, legal information and transportation,
provision of intercultural mediation, emotional
support, psychological first aid and family linking
services47.

© Alessandro Penso

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Our patients in Italy, who mainly come from
Eritrea, Gambia, Nigeria and Senegal, tell us
they fell sick during the migration journey andmore than half of them have skin problems, mostnotably scabies because of the poor hygiene
and sanitation conditions. More than half reportthat they experienced extreme violence; 70%
experienced a traumatic event before migration
and almost all experienced a traumatic event
during migration.
Vulnerable, unable to access basic services
and lacking information, asylum seekers andmigrants are also likely to suffer from mental
health disorders. Yet the screening and provisionof services for mental health issues are all but
absent from temporary state reception structures
where these populations are hosted while awaitinga decision on their claim. Psychological support
to refugee and migrant populations has therefore
become a medical priority for MSF in Italy.

“In some cases, people have been victims
of kidnapping or witnessed deaths. The
majority of individuals have risked theirlives and been detained, tortured andraped before and during their journeys toEurope. Many have experienced traumatic
events such as armed conflict or violence.
(…) When it comes to mental healthservices for asylum seekers it is crucial
for the psychologist not to focus solely on
the traumatic past. It is also fundamental
to understand the different forms of
psychological distress related to current
experience and the challenges faced in thepresent. While in the reception system,
asylum seekers have to live with theuncertainty of their future, the outcome of
their asylum requests and fear of being sent
back home. On top of this, the lonelinessthat many experience in the reception
centres affects them. In many cases, theseelements represent the most significant
obstacle to the re-establishment of thebalance in their mental well-being.”
MSF Psychologist in the psychological first aid team,Rome, Italy

MSF Medical activities in Italy

Between 1 January and 31
December 2015, MSF teams
provided 4,391medical
consultations to refugees andmigrants in Italy.
Pozzallo CPSA)In the Pozzallo reception centre, MSF has beenworking since January 2015 with the Italian
Ministry of Health to provide medical services torefugees and asylum seekers from the time they
disembark to the end of their stay in the centre.
Services include first aid care and medical
consultations for all new arrivals upon landing.
Our patients mainly come from Eritrea, Gambia,
Nigeria and Senegal and 10% are unaccompanied
minors.

© Ikram N’gadi

PFA Sicily
Since May 2015, a mobile team of cultural
mediators and a psychologist has been providing
psychological first aid at different landing points
in Italy. The team is on standby to be deployedwithin 72 hours of receiving an alert and can give
support to people who have suffered particularly
traumatic experiences at sea and need urgent
psychological care upon arrival.

Between 30 January and 31 December 2015,
MSF teams carried out 3,339 consultations ofwhich 392 were for children.

Between late May and late September 2015,
the team intervened in 14 traumatic events in 8
different harbors in southern Italy, taking care ofnearly 2500 people.

Main morbidities included 49% skin infections(scabies represents 39% out of the 49%), 15%
respiratory diseases and 6% gastrointestinal
diseases.

PFA Roma

CAS Ragusa province
In the 16 secondary reception centres where
MSF operates in the Ragusa province of Sicily,an MSF mental health team is on hand toprovide direct psychological support to the
refugees and migrants. Most of the patients
we treat come from Nigeria, Gambia, Senegal,
Mali and Bangladesh. 41% of them present
symptoms of post-traumatic stress disorder,
while others suffer from psychological distressand depression.

In July MSF set up a psychological first aid projectproviding services mainly to asylum seekers intransit in the two settlements of Baobab Centre
and in the temporary tent camps in the area ofTiburtina Station in Rome. Main activities include
the provision of information (legal, health relatedetc.), vulnerability screening and psychologicalsupport.
Between 16 July and 1 November 2015, MSF
teams provided information to 6,540 people,
provided emotional support to 903 people
through individual or group sessions and carriedout 79 individual psychological consultations.

Between 30 January and 31 December 2015,
MSF teams carried out 1052 individual mental
health consultations and organised 69 groupsessions for 549 people.
© Christophe Stramba-Badiali / Haytham Pictures

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Step 4 : Transiting from South to North Inhumane transit throughWestern Balkan routes“I feel like this is a journey from hell to the unknown.”
Syrian woman, 22 years old, travelling with husband and two small children, Sid, October 2015

In light of the lack of assistance and protection in Greece, most refugees and migrants leave quickly
and continue their journey through the Western Balkan route in order to reach European countries
such as Austria, Germany and Sweden where they can seek protection.
The Western Balkan route is fraught with difficulties and danger. It is subject to frequent and confusingchanges as state borders open and close with little warning. In November 2015 the route was mainly
from Greece to the Former Yugoslav Republic of Macedonia (FYROM), then through Serbia, Croatia, andSlovenia towards Austria, Germany, Sweden and other European countries.
Throughout 2015, this route registered a huge increase in the numbers of refugees and migrants intransit.
• FYROM, the main corridor for people travellingfrom Greece to Serbia registered 214,343
people passing through the country between
19 June and 5 November 201548, averaging an
estimated 6,922 a day in early November49.
• As of 11 November, 404,022 migrants andrefugees had entered Serbia in 2015, which
represented about 6,343 people arriving per
day in early November50.
• As Hungary closed its borders in thesummer, the flow of refugees and migrants
went exclusively through Croatia. Between
16 September and 10 November 354,446
migrants and refugees were registered as
passing through the country51, averaging
6,853 people a day in early November52.

© Borja Ruiz Rodriguez / MSF• According to the Slovenian government,close to 200,000 refugees and migrants
entered Slovenia between 16 October and 13
November53, with an average rate of 6,685
people per day in early November54.
With people continuing to flee their countriesof origin, the numbers transiting through theBalkans are unlikely to drop dramaticallyduring the winter. Between November 2015 andFebruary 2016, UNHCR anticipates an average of
5,000 arrivals per day from Turkey, resulting in up
to 600,000 arrivals into Croatia, Greece, Serbia,
Slovenia and the FYROM55.

© Florian Lems / MSF

An unpredictable journey through theBalkans, fraught with difficulties“We went to Macedonia, we crossed theborder and we ran and ran and ran. A
guy I had met one day before and who
was with us started to breathe fasterand faster. I tried to help him, I tried
to give him some breaths, but his soul
just got out of his body, his eyes went
strange, his lips went blue. My friends
and I did not know what to do. We wereon a mountain, so we could not bury him
there. So we left him near the border.
We felt guilty, we felt very guilty about it.
This is the way we have to behave in thissituation.”
23 year old man from Syria, Serbia

In the first half of 2015, patients we treatedthroughout the Balkans told us stories of being
beaten and robbed by criminals, harassed andpushed back by border police on the way, andforced to sleep in the cold. When they arrived
at our clinics in Serbia, they were exhausted
and, in their own words, felt “humiliated” by theconditions that they faced, including sleeping
outside and drinking dirty water from puddles.

“I’m from Syria. I have four young
children. I travelled from Greece toMacedonia but was arrested anddeported back to Greece four times. I
was molested by the Macedonian police.
They took all my money. On the roadto Serbia the mafia stopped me, took
all my belongings and left me in an
isolated area. When I went to ask the
Serbian police for help, they put me inprison for 10 days and then deported
me to Macedonia. I returned to Serbia
and continued to Hungary. There, I wasarrested, handcuffed and thrown in acell without water or food. I was thirsty
and sick, but when I asked for water, thepolice officer replied : “I’ll piss in a cup
and you’ll drink that!”

In the second half of the year, there was a slightshift which enabled a swifter and safer movementof people through the Balkans. Between late
July and the first two weeks of November 2015,
new asylum policies and improved transportarrangements enabled thousands of people tocross borders legally without having to resort
to smugglers, and reduced people’s journey bydays or weeks.
Indeed, after a series of fatal accidents involving
people travelling through the country via
dangerous routes to avoid arrest56, FYROM
changed its asylum law on 16 June 2015.
According to this new law, people registering
their intention to apply for asylum could remain
in Macedonian territory legally for 3 days andde facto cross the country57. In Serbia, a similarsystem was already in place, as registration
papers valid for 72 hours enabled refugees andmigrants to travel from its border with FYROM
to its border with Croatia. In the first week ofNovember 2015, authorities put in place a train
service which transported refugees and migrants
from Šid (Serbia) directly to the reception centre
in Slavonski Brod (Croatia) and from there
to Dobova (Slovenia)58. From Dobova, people
were transferred to centres near the Austrianborder, and eventually made their way to their
final destinations in Europe, be that in Austria,
Germany, Sweden, or further afield.
In mid-November 2015 these arrangements
fell apart, as Slovenia, Croatia, Serbia and the
FYROM took the arbitrary decision to only allow
people who had registered as being from Syria,
Afghanistan and Iraq to transit through theirterritories.

Syrian man, Bogovadja forest, Serbia© Borja Ruiz Rodriguez / MSF

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The domino effect of border closures

Below are details of some of the main recent
border closures :“I feel so lost now. There are still two other countries in Europe [to travel through].
A trip to Mars to me is closer! I don’t think I’m still able to go on such risky trips
again. I really don’t know what to do…”
Syrian man living in a forest in Serbia with his wife and their six year old son

Rash decisions to close borders and a lack of coordination between different European states havecreated incredible stress and dangerous conditions for thousands of people on the move. Eachtime a border closes, thousands are abruptly halted, stranded in no man’s lands, with little to nohumanitarian assistance, and ultimately, forced onto more dangerous routes or into the handsof smugglers. Far from stemming the flow of people on the move, these restrictions have merely
made people’s flight to safety more dangerous and more miserable.

GERMANY• On 16 September 2015 Hungary closed its
border with Serbia and announced it would
start arresting people who crossed theborder irregularly. Around 5,000 refugees
and migrants faced fences, police violence(including the use of tear gas) and were left
in limbo in a no-man’s land 62. This caused
the number of asylum seekers transiting
through Croatia to dramatically increase .

SLOVAKIA
AUSTRIA
Hungary
ROMANIA
CROATIA
BOS. &HER.

SERBIABULGARIA

ITALY

MACEDONIAALBANIAGREECE|42• In 2013 Bulgaria finished erecting its fencewith Turkey, blocking the flow of refugees
arriving maily from Syria and forcing themto take the dangerous sea route fromTurkey to Greece60.
• On 20 August 2015 the FYROM (Former Yugoslav Republic of Macedonia) government
decided to close its border with Greece anddeclared a state of emergency. This resulted in violent clashes between Macedonian
security forces and the refugees61. During
the ensuing three days of tensions, FYROM
border police used tear gas, stun grenades
and rubber bullets. The border was subsequently re-opened.

POLANDSLOVENIA• In 2012 Greece built a fence on its borderwith Turkey, which was a key crossing point
for refugees and migrants. It also increased
security along the Evros River, which forms
the remainder of the border. This is thefirst of several barriers that have diverted
the flow of migrants to more dangerous
destinations such as Bulgaria or onto boats
leaving Turkey for the Greek islands59.

TURKEY• On 16 October 2015 Hungary closed its
border with Croatia, forcing people to moveon to Slovenia or stay in Croatia63. Slovenia
initially set a cap of 2,500 entries per day.
But with between 3,500 and 6,500 people
transiting daily from Serbia to Croatia,
this caused a bottleneck on the border
between the two countries. About 3,000
people were stranded every day for several
days64. Women, children and disabled
people were forced to sleep in the cold,
the rain, and the mud, with no shelter andno assistance65. Further ahead, between
Croatia and Slovenia, the refugees andmigrants that had managed to cross theborder to Croatia faced new difficulties
as they were forced to cross river points
due to border restrictions66. They foundthemselves stuck in a no man’s land, whilsthumanitarian organisations couldn’t reachthem to provide them with much needed
assistance.
• On 11 November 2015 Slovenia began
preparations for a fence on its border with
Croatia. According to the Slovenian Interior Ministry, temporary barriers extending
over 4.5 km would be set up as a preventative and temporary measure to control
and direct the flow of refugees to wherereception centres are located. Destination
countries are increasingly reluctant tocontinue accepting asylum seekers, andthis reduction in capacity is putting pressure on countries further up the chain toblock further arrivals.
• On 18 November 2015 Slovenia, Croatia,
Serbia and FYROM’s decision to only allow
nationals from Syria, Afghanistan and Iraq
to enter their borders created a dramatic
humanitarian situation. In a noticeably
concerted effort, the four countries all
suddenly changed their border management
practices, without prior notice, and with nocontingency planning. FYROM was the first
country to act, refusing entry to nationalities
other than the three detailed above, and attimes even shutting the border completely.
The same day, around 440 people were
blocked from entering Croatia at its borderwith Serbia, with border police from bothcountries working together to prevent
people getting on trains at Sid. As a resultof these restrictions, thousands of refugees
and migrants in clear need of protection
were stuck for days in the Greek-FYROM
border town of Idomeni, with no shelter andlittle assistance. Indeed, on the night of 19
November, 6,000 people were left stranded
at Idomeni, with shelter available for
only 900 people. MSF teams dramaticallyincreased the shelter capacity and medical
teams worked hard to meet the increasing
health needs of groups of people that were
stranded.

43|© Achilleas Zavallis

Authorising transit across the Balkans had
so far been the only realistic response to
the failure of the European asylum system
and Greece’s inability to offer assistanceand protection. This sudden policy change,
implemented without any consideration ofpeople’s protection, medical or shelter needs,
shows once again the incapacity of European
and Western Balkans States to provide
coherent and humane solutions to the needsof desperate people in search of protection.

Refugees were stranded in the border
between Serbia and Croatia.

“We don’t know what is happening,
but we can’t pass Croatia and here
I don’t know what is happening. In
Croatia the police were very bad.
They pointed guns and sent us backand beat us. Look at my foot : The
policeman threw me to the floor andjust started kicking and kicking. I
don’t understand. We have the papers
from Greece, Macedonia and Serbia
but they didn’t let us pass and sent us
back, like animals”,
22 year old Moroccan man, Sid, November 2015

• In late November 2015 the FYROM started
building a fence on its border with Greece,with the alleged aim of controlling the flowof migrants through the Balkans.
Everyone has the right to seek asylum, andrefugee status and protection needs cannot be
judged based on nationality alone. Decisions
by states to close their border or to only allow
people from certain nationalities to cross, arbitrarily, and discriminatorily deny many thousands of people access to asylum procedures.
Such decisions take effect with little or no
warning or preparation and leave thousands ofpeople stranded in dire conditions with no assistance. This means that humanitarian agencies constantly have to adapt to new crises andcannot offer appropriate assistance. Finally,such policies increase anxiety among the people in transit who lack information and experience extreme uncertainty about their future,
resulting in higher levels of tension within
the transiting population and amongst borderpolice who must deal with increasingly tense
populations trapped between borders.

|44

As well as difficulties created by borderclosures, the journey from southern to northwestern Europe remains extremely harshand challenging, mainly due to the lack ofassistance and response from State agencies
and regular violence. Indeed, if incidents at thehands of smugglers and criminals have slightly
decreased, migrants and asylum seekers
continue to experiment violence, mainly fromstate security forces not able to keep the peacein the crowds of people trying to cross borders.

“Bulgaria is an EU country, I cannot
believe it, I am so angry. I’m sorry forspeaking like this. But the police werereally bad. It can’t be called police,
it is mafia. They took our money, ourphones. They beat us, even women.
We are running from Daesh in Iraq
but I didn’t know there was a Daesh
in Bulgaria.”

Significant challenges and gaps also remain in
the assistance that is provided to the refugees
and migrants on the move. These include a lackof adequate winterized shelter while transiting,ill-adapted crowd management and transit
procedures, a huge gap in information and acontinuing lack of transport67. Smugglers andsome taxi drivers exploit this lack of informationand free transportation, influencing refugees andmigrants to bypass the registration process andcharging them extremely high amounts of money
to continue their journey.

“On the border with Macedonia (Presevo)
we were waiting for almost four days tobe registered. I had to stand the whole
day in a very long queue, holding my child,and for the first three days I didn’t makeit. Whenever some tension happened thequeue was messed up and we had to start
all over again. Then here [Sid] as well we
tried to cross the day we arrived but theweather was too bad to wait for our turn;my children got sick and we had to go tosome hotel to stay for the night. The next
day we took a taxi to the border again,
then again it was so crowded and we
stayed there for more than seven hours
without being able to pass. And today here
we are again, so exhausted, the children
in a bad condition, I am praying to crosstoday, we can’t take it any longer.”
22 year-old Syrian woman, Sid, Serbia-Croatianborder, 21 October 2015

Iraqi man travelling with his family, Dimitrovgrad,
October 2015
© Anna Surinyach

45|

A further toll on people’s physical andmental health“During all our time in Macedonia weonly slept outside in forests. We wereaccompanied by a group of people,
among them there were two older
women. One was 55 years old and theother 65. They were rapidly exhausted.
This mountain crossing was extremely
difficult, like a special forces training.
One almost drowned crossing a river,
she could not see well in the dark andfell down in the water. The other one
hurt her foot very badly. At some point,
the women could not take it anymore
and we decided to hand ourselves overto the police so that they could get
medical care.”32 year-old Syrian Palestinian man, Bogovadja,
Serbia, January 2015

Throughout the Balkans, MSF teams aretreating patients suffering from the healthconsequences of the dangerous and difficult
journey they face. As winter has descended,
temperatures have dropped, the rain has set inand thousands of people are repeatedly stuck
in inhospitable border areas. As a result of
these difficult conditions and the lack of shelter
and hygiene, MSF teams in Greece, Serbia
and Slovenia have been increasingly treating
medical conditions linked to the cold weather
and lack of shelter. In Serbia, 80% of medical
consultations provided by MSF have been
for conditions related to the tough journey,
including respiratory tract diseases (42%),
trauma and musculoskeletal ailments (19%)
and skin diseases (9%).
When FYROM closed its border with Greece inAugust 2015, MSF teams treated 406 patients,
mostly injured people. In the second halfof October 2015, MSF teams in Brezice, atSlovenia’s border with Croatia, and MSF teams
in Serbia were mainly treating patients withexhaustion, hypothermia, respiratory diseases,
flu-like
symptoms
andgastrointestinal
diseases, as most had had to spend the night
outdoors in the cold and with no access to basic
sanitation.

|46“Patients often ask us if they can takea shower and wash here. The feelingof not being able to take care of yourpersonal hygiene is demeaning, andhas psychological as well as physicaleffects. People have all reached thelimit of what they can take – some havealready gone beyond it. The situation is
simply unbearable.”
MSF Nurse working in Brezice, Slovenia, November
2015

In November 2015, as new regulations prevented many people crossing from Greece to the
FYROM, thousands of people were left strandedon the border. Between 18 November and 13
December, MSF teams in Idomeni carried out
1,638 medical consultations. Linked to the cold,
the rain, the lack of shelter and adequate assistance, medical teams treated 13 patientsfor hypothermia, one patient for frostbite andseven patients for dehydration. Sixteen patients
also presented to our clinic for medical care or
psychological support, reporting that they had
been beaten by police from the FYROM.
As is often the case, the trauma of the journey
and the added stress created by borderclosures have an impact on people’s mental
health. In late November 2015 in Iidomeni,
our psychologists noted a significant increasein the number of panic attacks and self-harm
attempts they witnessed each day, a directconsequence of the dire conditions faced bypeople at the border and ongoing uncertainty
about their future. In November 2015 in Serbia,
out of 91 individual mental health sessions, ourmedical teams treated patients with anxiety(33%), acute emotional reaction (26%) anddepression (10%). Between July and November
2015, 1,573 people participated in group mental
health sessions organised by our teams in
Serbia and 281 patients received individual
mental health consultations. Of the lattergroup, a third were women, 13% were minors
and a quarter reported having been victims of
torture carried out in their country of origin.

MSF medical activities in
the Balkans

Between 1 January and 27
December 2015, MSF teams
provided just over 40 000
medical consultations in
the Balkans
Serbia
MSF has been working in Serbia since December
2014, running mobile clinics in different borderareas, providing mental health support anddistributing essential relief items. Our operations
have remained flexible and mobile in order toadapt to the constantly changing context at theborders with FYROM, Hungary, Bulgaria andCroatia and in and around Belgrade.
At the Serbia-FYROM border, MSF has been working In Miratovac and Presevo, providing medicalcare and transport to refugees and migrants. In
Presevo, where a reception centre has been built,
MSF has set up toilets and tents to keep refugees
sheltered from the rain. For the period 16 June2015 – 9 December 2015 we undertook 9,184
medical consultations of which 26% were womenand 11% were children under five years old.
In Subotica, a small town on the Serbo-Hungarianborder, MSF provided medical services and NFI
distributions to refugees and migrants in the oldbrick factory where people stopped over before
crossing to Hungary. For the period 5 December
2014 – 17 September 2015 (when the project
closed), MSF provided 3,134 medical consultationsof which 14% were women and 5% were children
under five years old. In addition, 729 NFI kits were
distributed.
In Belgrade, MSF teams provided medical care to
refugees in two parks close to the train and bus
stations. For the period 17 April 2015 – 15 September 2015 (the point of the project’s handover) we undertook 3,950 medical consultationsof which 21% were women and 9% were children
under five years old
In Sid, at Serbia’s border with Croatia, MSF operates a clinic that provides medical care, and is
finalising the construction of a temporary wintershelter with a capacity for 1,200 in the new transit
points set up by authorities. Between 17 September 2015 and 5 December 2015 MSF undertook
15,244 medical consultations of which 21% were
women and 8% were children under five years old
Hungary
In early September 2015, MSF set up a mobile clinic
in Roszke on the Hungary-Serbian border, wherean estimated 2,000 people a day were crossing into
Hungary. MSF medical teams treated 690 people,
including 400 people in just four days of whom
60% were children. Exhausted from the toughand dangerous journey, many were suffering from
respiratory problems and infected wounds fromthe long walks.
As borders closed, causing people to be stuckon the Serbian side, MSF reinforced its teamsin Horgos and Subotica, and as the Roske camp
emptied and refugees moved to Croatia, MSF
moved its operations to Croatia.
Croatia
Between early September and early November
2015, MSF teams provided medical care on Croatia’s border with Serbia in a transit camp in Opatovac near Tovarnik, where refugees spent about a
day before being transferred to Hungary. MSF set
up a clinic in the camp, which hosted around 5,000
people daily, and it also deployed mobile clinics
to rapidly assist refugees at the different crossing
points, including Bapsaka and Sid. Medical teams
carried out 4,391 consultations, many of them for
respiratory infections (due to the cold, the precarious living conditions and the long journey), gastrointestinal problems and skin diseases. The majority of the patients were children.
Slovenia
Between 20 October and early November 2015,
MSF teams supported the Ministry of Health at
the Brezice transit centre at Slovenia’s borderwith Croatia. Twenty four hours a day medical
staff provided medical assistance to people
entering the Slovenian territory, mainly for
exhaustion, hypothermia, respiratory infections
and flu symptoms. In late October, trains wereorganised from Croatia to bring people directly to
the Austrian-Slovenian border and as a result theBrezice transit centre was closed.

47|

As winter sets in and the movement of refugees and migrants through the Balkans is slowed
and at times blocked, thousands of men, women and children’s ability to seek asylum andassistance in Europe is being jeopardised and their health and safety are being put at further
risk.
The end of the journey, but a continuing obstacle course…
Spurred on by inadequate reception conditions in first countries of arrival, hundreds of thousands of refugees and migrants continue their perilous and arduous journey until they reachWestern Europe.
Whilst MSF has concentrated its operations in entry and transit countries where state
capacities have struggled the most to cope with the humanitarian needs of the refugees andmigrants, it is closely monitoring the situation in destination countries and providing support
if and when needed. Indeed, in recent months, more and more countries including Sweden
and Germany have expressed difficulties in providing the required shelter, vulnerability
screening and mental health support to the newly arrived refugees and asylum seekers68.
Below are some examples of MSF supporting activities in destination countries.
Austria : Both a transit and a destination country, Austria is expected to register over 80,000
asylum applications in 2015. Whilst authorities have mobilised resources to respond to theneeds of this population, some gaps remain and MSF provided medical support for three
weeks at the transit centre in Nickelsdorf on the Austrian-Hungarian border, and then moved
on to supporting the Red Cross at the transit site in Spielfeld on the Austrian-Slovenian
border. With numbers of people in the transit centre decreasing, this support ended in late
December 2015. In an accommodation centre in Graz, MSF teams also started mental healthactivities with asylum seekers.
France : In early September 2015, MSF joined forces with Médecins du Monde, following a
dramatic increase in the migrant and refugee population in Calais and other smaller towns
in the region. In the so-called ‘Calais Jungle’ alone, the population had increased to morethan 6,000, which has overwhelmed organisations and volunteers working hard to assist
this vulnerable population. Faced with the horrendous living conditions in the camp, MSF
started to support MDM medical activities and set up hygiene, water and sanitation activities.
From November onwards, MSF also set up mobile clinics in other towns in the Pas de Calais
area and in Dunkirk, where many migrants and asylum seekers are also living in very basic
conditions. Between in November and mid-December 2015, MSF teams in that area provided
2,172 medical consultations, the majority of which were for respiratory infections and scabies,
pathologies linked to the cold and unhygienic conditions.
Belgium : Whilst numbers of new asylum applications have remained relatively low in Belgium,
authorities were taken by surprise by the increase in arrivals in the second half of the year. In
September 2015, at the request of the federal agency in charge of assisting asylum seekers(FEDASIL), MSF supported the scaling up of reception capacity in the country by setting up
an emergency reception centre in Sijsele and contributed to increasing reception capacity infour existing centres. MSF also supported mental health activities led by other agencies andencouraged association members to volunteer with existing initiatives. As the government
failed to adapt to the needs of the continuing flow of asylum seekers, MSF intervened twice
more in September 2015 and November 2015 in support of civil society initiatives striving toprovide shelter to asylum seekers and migrants left on the streets.

© Alessandro Penso

|48

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A dramatic European
failure to respond to
the needs of refugees
and migrants in Europe
Despite the countless meetings, conferences
and plans that have been organised by theEuropean Union and its member states
throughout 2015, the European response to the
refugee and migration situation in Europe canonly be described as an overwhelming failure.
Very little of the EU response has focused on thehumanitarian needs of refugees and migrants
in Europe – and very little of what was finallyagreed on was implemented.
In terms of funding, the EU response, especiallyfor Greece, has suffered from the inadequacyof the bureaucratic EU funding mechanisms
available to respond to emergency situations.
Greece has also been slow in activating certain
EU emergency assistance mechanisms such as
the Civil protection mechanism, which it only
requested the assistance of on 3 December. As
a result, frontline countries like Greece havelacked funding for their humanitarian response
and NGOs willing to address these gaps have notbeen able to access funding to do so.

people’s access to protection has signally
failed to deliver. Additionally, it is unlikely that
relocation in Greece will ever succeed without afunctioning reception system.

“We are bringing our children throughall these risks and making them face
this cold because it’s the only guarantee
we will be together. The reunification
turns out to be a big lie. We heard thatthey are even starting to push people
back, especially males alone, so we
can’t trust reunification”.
24 year old Syrian woman, travelling with her baby
and relatives, Sid, November, 2015.
© Anna Surinyach

Clearly, as detailed throughout this report, mostof the EU’s efforts have to date concentrated
on deterrence measures70 aimed at stemming
the flow of refugees and migrants arriving on
its soil. And as is evident from the continuing

As for the relocation and resettlement schemes,
these have not been made mandatory andstates have mostly refused to participate. Asof 3 November 2015, 14 member states had
made 2,284 places available out of the 160,000
European relocation pledge and only 86 people
had effectively been relocated from Italy69. Heldback by lengthy administrative procedures, along list of requirements for refugees to meetand a lack of clarity about the process, what could
have been an important mechanism in ensuring

arrival of hundreds of thousands of refugees andmigrants in Europe, these deterrence measures
are a false and ineffective solution – serving only
to push people towards smugglers and moredangerous routes. Both these measures and thefocus on providing aid to countries of departure,such as large refugee camps outside Syria, donothing to reduce the flow or address thesevulnerable peoples’ urgent needs before or
during their flight. As a UNHCR survey recently
found, the majority of Syrians arriving in Europe
come directly from Syria rather than fromneighbouring camps. If increased humanitarianassistance is needed in these camps, it does not
absolve EU member states from fulfilling their
responsibilities, and humanitarian assistancealone will not fulfill the long term needs of Syrian
refugees.
Two other worrying developments are attempts
by the EU and its member states to use
humanitarian funds as a migration management
tool and using financial and political incentives
to persuade third party states to deter refugees
and migrants from arriving in Europe. This is aconcern for example with regards to the on-goingnegotiations with Turkey and African states.

© Alessandro Penso

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The shortcomings of the traditional aid
system and the emergence of new actors
One of the many characteristics of the
response to the large influx of refugees andmigrants in Europe has been the failure of
the traditional aid system, including MSF,
to respond adequately to the needs of thehundreds and thousands of refugees andmigrants in Europe.
Indeed, there has been an overwhelming
failure at coordinating assistance by the
EU States themselves, by UN  agencies
mandated to do so, such as the UNHCR,
and the wider traditional aid system.
Through their lack of preparation, lackof resources or lack of willingness, someStates have in large part failed to provide
an adequate humanitarian response. UN agencies mandated to support states inthis response, have struggled to step up
operationally themselves to fill this void. The
fact that in Europe UNHCR acts mainly as atechnical support in asylum matters has led
to a lack of reaction from the organization,
which did not see its role as being the samein Europe as in other regions of the world.
In Greece in particular, UNHCR protection
and coordination activities have been far too
limited, and as no authorities are willing tomanage transit camps, the crucial activityof camp management has been taken in
charge by volunteers or NGOs.
Similarly, international NGOs have beenslow to step up to the needs of refugees andmigrants travelling through Europe, be it
because of their lack of operational presencein such countries; their unwillingness to be
operational where states could theoreticallystep up to these needs; the difficulties
in providing assistance to populations inmovement; or obstacles put in their way byunwilling authorities.

was paralysed by uncooperative states orauthorities; struggling to adapt its models ofcare to very mobile populations; or unwillingat times to offer itself as a substitute for thestate’s responsibility. As such, MSF and otherorganisations have many lessons to learn
from this latest crisis.
Local and international civil society
organisations, activists and volunteers havefound themselves at the forefront of the
response to the refugee crisis throughout
Europe; and have led the majority of advocacy
and operational activities. At the core of theiractivities has been the upsurge of solidarity
from citizens across the world, volunteering
their time, donations and money to assist thetens of thousands of refugees and migrants.

Far from responding to the urgent need forprotection and assistance of refugees andmigrants arriving on its soil, the EU andEuropean governments have failed to harmonise
their policies and practices with regards tothe treatment of asylum seekers. Europe’s
protection and humanitarian responses havelargely failed to address people’s very basic
needs. In pushing the refugee flow onto others,
namely Turkey, Africa and Syria’s neighbouring
countries, Europe has largely refused to takeresponsibility for these vulnerable populations.
As a direct result, chaos has continued to ensue
on and within Europe’s borders, and refugees
and migrants continue to have to put their lives
at risk to seek protection, assistance and adignified life.

MSF, which already had a presence in manyof the countries affected, has been one of
the main international NGOs providing
assistance to refugees and migrants at sea
and on Europe’s roads. Yet its assistance has
also at times fallen short of the refugees
and migrants’ needs, either because it

Conclusion :An urgent call for change“After going through all this, I feel likeI’m dying sixty times every day. I wonder
what will my son say to me when hegrows older : Why did you take me out
with all these dangers around, to makeme face death a million times in one
hour? Did you want to sacrifice me foryour own sake? Of course I didn’t. I had
either to let him be slaughtered or takehim in a death trip.”
Syrian man living in a forest in with his wife and his
6-years old son, Serbia, January 2015.

In 2015, Europe shamefully failed to respond to
the needs of refugees and migrants on its shores
and within its borders. Escaping persecution andviolence, just over a million people desperate
for protection and assistance were faced witha hazardous obstacle course where they least
expected it – through Europe. Despite a declared
willingness to abide by its responsibility to treat
these people humanely and offer protection to
those in need, Europe turned its back on themas its focus shifted from a humanitarian to asecurity-driven response. Part and parcel of thatstrategy has been the Dublin Regulation72, which
has been key in criminalising refugees’ onwards
movement through Europe, thereby pushingthem to use irregular routes and smugglers.
The first country of entry rule, at the chore of theEuropean asylum system has largely contributed
to the crisis and allowed for no European country- at the temporary exception of Germany andSweden - to assume responsibility for thesepeople. Safe and legal means of seeking asylum
and migration were compromised by increased
border closures, more fences, further violence
and greater neglect.

The misguided fear of creating ‘pull factors’ haslong paralysed European states’ response on the
ground. The argument that rescuing people andimproving reception conditions will encourage
more people to migrate to Europe is not only
erroneous; it is also, above all, dangerous.
People fleeing war, human rights violations andextreme poverty will continue to attempt to reach
Europe whether or not states try to stop them.
Refraining from assisting them only results inmore obstacles, more suffering and more deaths
at sea and in transit.
Far from stemming the flow of refugees andmigrants, Europe’s lack of assistance and its
restrictions on movement have simply forced
desperate people to put their lives and healthat risk by resorting to the services of smugglers
and taking treacherous routes, including theextremely dangerous sea crossings in the
Mediterranean and Aegean Seas. Preying on
people’s desperation, smugglers are the violent
and abusive by-product of Europe’s shamefuland restrictive migratory policies.
Throughout 2015, MSF teams at sea, in Italy,
Greece, throughout the Balkans and in Western
Europe have treated refugees and migrants
for conditions linked to these policy-madedangerous and traumatic journeys. Our teams
continue to provide medical consultations at all
hours of the day and night, to distribute essential
items, to build emergency temporary shelterand create water and sanitation services. But
as a medical humanitarian organisation, MSF
does not hold the key to a solution and it can only
alleviate the consequences of these restrictive
policies on refugees and migrants’ wellbeing
and health.

© Alessandro Penso

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It is Europe and its member states that can andmust act. European member states have clear
obligations towards people seeking asylum basedon international and European legislations. As
such, every human being, regardless of his or
her legal status must be rescued at sea, given
dignified treatment and have effective access toasylum procedures.

An Afghan family at the pier on the island of Kos.

The EU and European
states are therefore
strongly urged to :• Swiftly provide safe and legal channels
for people seeking asylum, in particularallowing asylum seekers to apply for asylum at land borders, including the Evros
land border between Turkey and Greece.
This also includes making wider use ofexisting options and procedures, such as
for example : family reunification, humanitarian visas, resettlement and relocation.

Yet to date, Europe’s response to this crisis has
been an affront to the refugees and migrants’basic rights to assistance and dignity, and it is anaffront to core values of humanity and respectfor human rights. In denying vulnerable people
humanitarian assistance, and blocking andpushing people back based on their nationality
rather than vulnerability and protection needs,
Europe and its member states have eroded thevery foundations of international refugee andhuman rights law.

• Create legal migration pathways todecrease the demand for irregularmigration and smuggling networks.

As people are likely to continue seeking muchneeded assistance and protection in Europe in
2016, it is time for Europe to abolish its obstacle
course and provide assistance and safe andlegal passage to refugees and migrants fleeing
desperate conditions.

• Create an ambitious European search andrescue mechanism to save lives at sea.
This operation should proactively searchfor boats in distress as close to departure
points as possible and should be accompanied by pre-identified disembarkation
points where humane disembarkation
procedures, including medical care andvulnerability assessment, are in place.

“You know, the challenges we faceas refugees are like a footballchampionship, you have many stages
to win before you can reach the final.
Europe makes these stages so difficultthat people feel desperate; they pushthem back over and over again. Someget hurt, some die on the way or
abandon the journey. If you can play inthe final you are very lucky. It should not
be so hard to feel safe again…”• Invest in reception according to EU standards instead of deterrence measures only.
Europe must move away from a fortressapproach to a reception approach designed to address the needs and specificvulnerabilities of people arriving at its
borders, in particular their medical andmental health needs.
• In the absence of a functioning common European asylum system, invest
more ambitiously in intra-EU relocation
schemes and the creation of safe passage
through the EU.

32 year-old Syrian Palestinian man, Serbia• Put an end to acts of violence and abusefrom state authorities.

© Alessandro Penso

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end notes
1

UNHCR, Global Trends, Force Displacement in 2014,http ://www.unhcr.org/556725e69.html#_ga=1.264299530.4
46067460.1439971168.html

2European Commission, A Common European Asylum
System, 2014, http ://ec.europa.eu/dgs/home-affairs/elibrary/docs/ceas-fact-sheets/ceas_factsheet_en.pdf

3European Commission, Communication From The
Commission To The European Parliament, The Council,
The European Economic And Social Committee And
The Committee Of The Regions, A European Agenda On
Migration, 13 May 2015, http ://ec.europa.eu/dgs/homeaffairs/what-we-do/policies/european-agenda-migration/
background-information/docs/communication_on_the_european_agenda_on_migration_en.pdf

4European Commission, European Agenda on Migration– Legislative documents, http ://ec.europa.eu/dgs/homeaffairs/what-we-do/policies/european-agenda-migration/
proposal-implementation-package/

5

European Commission, Press Release : Meeting on theWestern Balkans Migration Route : Leaders Agree on
17-point plan of action, 25 October 2015, http ://europa.eu/
rapid/press-release_IP-15-5904_en.htm

6

7

8

9

European Council, Justice and Home Affairs Council, 20
July 2015, http ://www.consilium.europa.eu/en/meetings/
jha/2015/07/20/
European Commission, Press Release : Managing the
refugee crisis : Immediate operational, budgetary and legal
measures under the European Agenda on Migration, 23
September 2015, http ://europa.eu/rapid/press-release_IP15-5700_en.htm
European Commission, Communication From The
Commission To The European Parliament And To The
Council - EU Action Plan On Return, 9 September
2015, http ://ec.europa.eu/dgs/home-affairs/what-wedo/policies/european-agenda-migration/proposalimplementation-package/docs/communication_from_the_ec_to_ep_and_council_-_eu_action_plan_on_return_en.pdfEuropean Commission, Press Release  : A_european_border_and_coast_guard_and_effective_management_of_europes_external_borders, December 2015,http ://ec.europa.eu/dgs/home-affairs/what-we-do/
policies/securing-eu-borders/legal-documents/docs/
communication_-_a_european_border_and_coast_
guard_and_effective_management_of_europes_external_
borders_en.pdf

10 The Trust Fund is focused on the refugee response in
Lebanon, Jordan, Turkey, Iraq and Egypt. Actions mostly
include support to basic social services and “economic
resilience”. The total amount pledged since its creation in2014 is €610 million, of which €570 million are from theCommission budget and €40 million are contributions frommember states. - European Commission, EU Regional
Trust Fund in Response to the Syrian Crisis, http ://ec.europa.eu/enlargement/neighbourhood/countries/syria/
madad/index_en.htm|56

11 Initially presented as part of the refugee response, it
only affects African countries. It is development money“addressing the root causes of migration”. The total amountis €1,8 billion committed by the Commission through theEuropean Development Fund and €0,2 million pledgedby the EU member states. It will be based on the type ofprograms already supported through the Sahel and Horn ofAfrica resilience programs (mostly nutrition and livelihoods
support) - European Commission, Post : €1.8 billion TrustFund for Africa to improve stability and address root causesof irregular migration flows, 11 September 2015, https ://europa.eu/eyd2015/en/european-union/posts/trust-fundafrica
12 The Refugee Facility for Turkey is the legal basis for the €3billion EU contribution to the refugee response in Turkey.
The Commission has committed €500 million and EU
member states have pledged, but not yet committed, € 2,5billion - European Commission , Press release : EU-Turkey
Cooperation : A €3 billion Refugee Facility for Turkey, 24
November 2015, http ://europa.eu/rapid/press-release_IP15-6162_en.htm

24 UNHCR, Europe’s Refugee Emergency Response, Update#8, 23 - 29 October 2015
25 UNHCR, Press Release  : Mediterranean Crisis 2015 at six
months : refugee and migrant numbers highest on record,
1 July 2015 http ://www.unhcr.org/5592b9b36.html
26 MSF, Field News : MSF Trains Tunisian Fishermenin Saving Lives at Sea, 31 August 2015, http ://www.
doctorswithoutborders.org/article/msf-trains-tunisianfishermen-saving-lives-sea
27 MSF, Field News : MSF Saddened by Loss of Life
During Argos Ship Rescue, 16 June 2015, http ://www.
doctorswithoutborders.org/article/msf-saddened-loss-lifeduring-argos-ship-rescue
28 The Guardian, At least 29 migrants die of hypothermia
after Italian coastguard rescue, 9 February 2015, http ://www.theguardian.com/world/2015/feb/09/migrants-diehypothermia-italian-coastguard-rescue-libya-lampedusa

39 Cfr. Commissione Nazionale per il diritto di Asilo : http ://www.interno.gov.it/sites/default/files/quaderno_statistico_per_gli_anni_1990_2014.pdf
40 UNHCR, Europe’s Refugee Emergency Response, Update#8, 23 - 29 October 2015
41 Figures as of 10 October 2015 : 70 918 places in temporary
structures (CAS), 21 814 places in structures dedicated toreception of asylum seekers and refugees (second level
reception - SPRAR), 7290 in governmental centres for
asylum seekers (CARA) and 464 in retention and expulsion
centres (CIE). Report on the reception of migrants andrefugees in Italy, published by Italian MOI, October 2015,http ://www.libertaciviliimmigrazione.interno.it/dipim/
export/sites/default/it/assets/pubblicazioni/Rapporto_
accoglienza_ps.pdf

29 HRW, Greece : Attacks on Boats Risk Migrant Lives :Masked Assailants Attack, Disable Boats, Abuse
Passengers, 22 October 2015, https ://www.hrw.org/
news/2015/10/22/greece-attacks-boats-risk-migrant-lives

42 Piano di Contingenza Sanitario Regionale Migranti.
The Contingency Plan intends to provide a coordinatedresponse to the arrival of migrants and refugees at landing
spots by identifying responsibilities of Public HealthInstitutions at regional level and establishing the role oforganizations involved in the organization of the services atlanding.

14 European Commission, Press Release : EU-Turkey
Cooperation : A €3 billion Refugee Facility for Turkey, 24
November 0215, http ://europa.eu/rapid/press-release_IP15-6162_en.htm

30 Greece is now the biggest entry point for Syrians into
Europe43 As per indicated in the Hotspot Roadmap published by
Italian MOI.

31 UNHCR, Greece data snapshot, 20 November 2015, http ://data.unhcr.org/mediterranean/country.php?id=83/greece/

15 MSF, Editorial : Migration : Search and Destroy does not save
lives, 29 Mai 2015, http ://www.msf.org/article/migrationsearch-and-destroy-does-not-save-lives

32 Some of the visits include the visit of Commissioner for
Migration Dimitris Avramopoulos to Athens on 26 May;
Visit of vice-President Frans Timmermans and Dimitris
Avramopoulos on 3 and 4 September to Athens andKos; Visit of Dimitris Avramopoulos and Jean Asselborn,
Luxembourg’s Minister for Foreign and European Affairs,and Minister for Immigration and Asylum, on 15 and 16
October to Athens and Lesbos; Visit of Avramopoulos toAthens on 4 November

44 CAS (Extraordinary Reception Centres) : centres createdby Ministerial Decree of June 2014 to respond to the mass
influx of undocumented migrants and asylum seekers in
the country. They are currently used for the reception of
asylum seekers as per the status of CARA structures.

13 http ://www.africa-eu-partnership.org/en/newsroom/
upcoming-events/valletta-summit-migration

16 UNHCR, Refugees/Migrants Emergency Response –Mediterranean, http ://data.unhcr.org/mediterranean/
regional.php
17 Turkey’s land borders with Bulgaria and Greece are bothshut, and legal avenues such as resettlement and family
reunion to Europe are generally reducing (European Union
Agency for Human rights, Legal entry channels to the EU
for persons in need of international protection : a toolbox,
http ://fra.europa.eu/sites/default/files/fra-focus_02-2015_
legal-entry-to-the-eu.pdf)
18 UNHCR, Refugees/Migrants Emergency Response –Mediterranean, http ://data.unhcr.org/mediterranean/
regional.php
19 UNHCR, Refugees/Migrants Emergency Response –Mediterranean, http ://data.unhcr.org/mediterranean/
regional.php
20 UNHCR, Europe’s Refugee Emergency Response, Update#8, 23 - 29 October 2015
21 UNHCR, Refugees/Migrants Emergency response in the
Mediterranean, 2 November 2015
22 UNHCR, Europe’s Refugee Emergency Response, Update#8, 23 - 29 October 201523 UNHCR, Mediterranean takes record as most deadly stretchof water for refugees and migrants in 2011, Briefing Notes, 31
January 2012, http ://www.unhcr.org/4f27e01f9.html

33 UNHCR, Daily estimates – Greece, 7 December 2015, http ://data.unhcr.org/mediterranean/country.php?id=83/greece/
34 European Commission, Press Release : State of Play :Measures to Address the Refugee Crisis, 4 November
2015, http ://europa.eu/rapid/press-release_IP-15-5958_
en.htm
35 For other testimonies on living conditions in Kara Tape, see
http ://www.msf.org/article/greece-testimonies-migrantsand-asylum-seekers-lesbos
36 As Syrian refugees are given the priority, they usually stayfor shorter periods
37 See Directive 2013/33/EU of the European Parliamentand of the Council on laying down standards for the
reception of applicants for international protection.
Available here : http ://eur-lex.europa.eu/legal-content/EN/
TXT/?uri=CELEX :32013L0033
38 MSF, EU and Greece turn their backs on refugees arriving
at Greek islands, December 2014, http ://www.msf.org/
article/eu-and-greece-turn-their-backs-refugeesarriving-greek-islands

45 But also Sudanese, Ethiopian (both Amhara and Oromo),
Nigerian.
46 They often take a few days rest while they get in touch withfamilies and friends, waiting for the money to buy tickets
while collecting useful information to engage in the next
step of their journey.
47 In May 2015, following the dismantlement of the informal
settlement of Ponte Mammolo in Rome, a population of
migrants and refugees (both settled and transient) moved to
the Baobab Centre (run by volunteers) and to the Tiburtina
area, behind one of Rome Train Stations where, lately, theItalian Red Cross set up a temporary tents’ camp.
48 IOM, Situation Report : Europe / Mediterranean Migration
Response, 12 November 2015, https ://www.iom.int/sites/
default/files/situation_reports/file/Europe-Med-MigrationResponse-Sitrep7-12Nov2015.pdf
49 IOM, Interagency Operational Update, 2_16 November
2015, http ://reliefweb.int/sites/reliefweb.int/files/
resources/InteragencyOperationalUpdate3-16Nov.pdf
50 IOM, Situation Report : Europe / Mediterranean Migration
Response, 12 November 2015, https ://www.iom.int/sites/
default/files/situation_reports/file/Europe-Med-MigrationResponse-Sitrep7-12Nov2015.pdf
51 IOM, Interagency Operational Update, 2_16 November
2015, http ://reliefweb.int/sites/reliefweb.int/files/
resources/InteragencyOperationalUpdate3-16Nov.pdf

57|

52 IOM, Situation Report : Europe / Mediterranean Migration
Response, 12 November 2015, https ://www.iom.int/sites/
default/files/situation_reports/file/Europe-Med-MigrationResponse-Sitrep7-12Nov2015.pdf
53 Republic of Slovenia, Press Release : Slovenia has received
200,000 refugees to date, 13 November 2015, http ://www.
vlada.si/en/media_room/government_press_releases/
press_release/article/slovenia_has_received_200000_
refugees_to_date_56970/
54 IOM, Situation Report : Europe / Mediterranean Migration
Response, 12 November 2015, https ://www.iom.int/sites/
default/files/situation_reports/file/Europe-Med-MigrationResponse-Sitrep7-12Nov2015.pdf
55 UNHCR, Press Release : UNHCR launches appeal to aid
refugees as winter hits Europe, 5 November 2015, http ://data.unhcr.org/mediterranean/flash_read.php?ID=56

69 IRC, Urgent Humanitarian Action Needed on European
Refugee Crisis - International Rescue Committee Briefing,
4 November 2015, http ://www.rescue.org/press-releases/
urgent-humanitarian-action-needed-european-refugeecrisis-international-rescue-commit
70 European Commission, Press Release : State of Play :Measures to Address the Refugee Crisis, November 2015,http ://europa.eu/rapid/press-release_IP-15-5958_en.htm
71 Such measures include the strengthening of bordercontrols and patrolling, focus on return, fight against
smuggling
72 ECRE, Dublin Regulation, http ://www.ecre.org/topics/
areas-of-work/protection-in-europe/10-dublin-regulation.
html

56 VOA, Macedonia Allows Migrants to Legitimately Transit
Country , 18 June 2015, http ://www.voanews.com/content/
macedonia-migrants-asylum-law/2828577.html
57 ACAPS, The Balkans : Asylum Seekers, Migrants, andRefugees in Transit, Briefing Note Update, 17 November
2015
58 ACAPS, The Balkans : Asylum Seekers, Migrants, andRefugees in Transit, Briefing Note Update, 17 November
2015
59 The New York Times, Closing the Back Door toEurope, 16 October 2015, http ://www.nytimes.com/
interactive/2015/09/15/world/europe/migrant-borderseurope.html?_r=0
60 See Frontex, FRAN Quarterly Q3 report, July-September
2014, http ://frontex.europa.eu/assets/Publications/Risk_
Analysis/FRAN_Q3_2014.pdf
61 MSF, Migration : MSF receives 10 people with wounds
from Macedonian stun grenades, 21 August 2015, http ://www.msf.org/article/migration-msf-receives-10-peoplewounds-macedonian-stun-grenades
62 CNN, Refugee crisis : Hungary uses tear gas, watercannons on migrants at border, 16 September 2015, http ://edition.cnn.com/2015/09/16/world/europe-migrant-crisis/
63 The Independent, Refugee crisis : Hungary closes Croatianborder to refugees ‘from midnight’, 16 October 2015,http ://www.independent.co.uk/news/world/europe/
refugee-crisis-hungary-closes-croatian-border-torefugees-from-midnight-a6697071.html
64 BBC, Migrant crisis : Trapped in no-man’s land at the
Croatia/Serbia border, 19 October 2015, http ://www.bbc.
com/news/world-europe-34577506
65 Reporters Without Borders, RSF condemns Croatianpolice violence against foreign journalists, 21 October
2015, http ://en.rsf.org/croatie-rsf-condemns-croatianpolice-21-10-2015,48465.html
66 Channel Four News, Migrants cross through freezingwater in the dead of night, 21 October 2015, https ://www.
facebook.com/Channel4News/videos/10153292236781939/?fref=nf
67 BBC, Migrant crisis : Huge registration queues on SerbiaMacedonia border, 8 September 2015, http ://www.bbc.
com/news/world-europe-34183456
68 The Local, Sweden can no longer guarantee refugee beds,
5 November 2015, http ://www.thelocal.se/20151105/
sweden-urges-refugees-to-stay-in-germany|58

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