CONSTRUCTING CRISISAT EUROPE'S BORDERS
The EU plan to intensify its dangerous
hotspot approach on Greek islands

JUNE 2021

Table of contents

1

Executive Summary

4

Introduction
5

7

The EU hotspot: containment strategy on the Greek islands

The Human Cost of Containment
8

Mental health deterioration among adults

10 Children at risk: mental health
11 Children at risk: physical health and well-being
11 Sexual violence and a chronic lack of protection
12 Systematic gaps in healthcare
13 The COVID-19 effect: conflation of public health and migration control
14 The ‘Shield’ of Europe: Normalisation of Push-backs

and Violence at Borders

16 The EU’s Dangerous Hotspot Experiment
16 The everyday violence of containment
18 Failure to identify and protect vulnerable people
20 Erosion of asylum: ‘Fast track’ procedures and return
21 The expansion of detention
22 Moving Forward: EU Intensifies its Dangerous Approach
22 The renewed and intensified hotspot approach: MPRIC red flags
26 Conclusion
28 References
30 Annex: Reported Deaths in Hotspots

Cover:
Asylum seekers behind a razor wire fence in Vathy
hotspot, Samos, March 2016, © GUILLAUME BINET/MYOP|2

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

Executive Summary

Over the past five years, an entirely avoidable andpredictable policy-driven humanitarian crisishas been unfolding in the Greek islands of Lesvos,
Samos, Chios, Leros, and Kos, with devasting
consequences for the people trapped there. After
fleeing their homes and surviving harrowing
journeys to Europe, the indefinite containment,
limbo, and systematic violence in Greece further
traumatises people seeking protection. Nearly
10,000 people are currently being held in five
Greek islands ‘hotspots’, also known as Reception
and Identification Centres (RICs1).

the situation, the EU and its member states intend
to intensify and institutionalise its containmentand deterrence strategy.

In September 2020, the notorious Moria RIC
was burned to the ground in a destructive andsymbolic moment. EU leaders promised ‘nomore Morias’ while ignoring similar facilities on
Samos, Kos, Chios, and Leros. From the ashesof Moria has emerged a new, temporary camp,
Mavrovouni, that replicates many of the worst
elements of the Moria hotspot. The Moria RIC is
the blueprint for the proposed EU Migration andThe ‘hotspot approach’ has been envisaged as a Asylum Pact screening and asylum regulations
model of operational support by the EU agencies announced on 23 September 2020, and theto the Member States such as Italy and Greece to new EU-funded Multi-Purpose Reception andfacilitate the swift identification, registration, and Identification Centres (MPRICs) - one is being
fingerprinting of migrants arriving in Europe. In built on Samos and may be operational in June
Greece, this approach is closely intertwined with 2021. Commonly referred to as ‘closed centres’ by
the implementation of the EU-Turkey Statement the Greek authorities, MPRICs are designed as(also known as the ‘Deal’) and has proven to be more restrictive versions of the current facilities,
a disaster. The Deal signified a tipping point, and reinforce the ability to contain, detain andcreating a European border that is fortified and deport people arriving in Europe.3
closed; embedding structural violence at the heartof EU migration policies. After the introduction of In this report, MSF takes stock of five years of
the Deal, the hotspots quickly transformed into providing medical care on the Greek islands. The
mass containment sites intended to facilitate the report’s analysis is based on documentation andfast-track border processing and return of people medical data from MSF operations on Lesvos,
to Turkey. Thousands of people remain confined Samos, and Chios, as well as testimony fromin degrading and inhumane conditions as they patients and MSF staff.
wait for protection.
MSF once again calls on European leaders andAs a humanitarian medical organisation providing the Greek government to take accountability,
care on the Greek islands, Médecins Sans recognise the harm caused and end this deadly
Frontières (MSF) has been treating the physical and dangerous approach.
and mental wounds these migration policies haveinflicted on people for many years. In October
2016 and October 2017, MSF published several
reports highlighting the health implications ofcontainment and the significant mental healthemergency emerging on the islands.2 Nearly four
years on and, astonishingly, rather than address

The EU plan to intensify its dangerous hotspot approach on Greek islands

1|

“What we found in Moria was inhumanityand violence. It was an open-air prison. We
are survivors of torture, but in Moria we were
not even treated as human beings. We weretold that our country of origin is safe and that
we would be rejected and returned. We weretold that it didn’t matter what we had been
through. We didn’t receive any protection. We
didn’t receive any support. We weren’t eventold what the decision of our asylum application was. We didn’t have access to a fairasylum process. Now that we have been freed
from this hell, we call on you to stop treating
human beings like criminals on the Greek
islands. We don’t want more lines to queue
for food, people left without dignified shelter,no more people trapped in uncertainty andinsecurity. We who have suffered the mostdegrading and insurmountable violence,cannot but refuse inhumane and degrading
treatment for anyone in any way. Every
person deserves to be treated with humanitywith respect to their dignity and freedom.”
Survivors2 is a group of survivors of torture,
cruel and inhumane treatment, and EU
migration policies. All Survivors2 members
are either current or former patients of MSF’s
rehabilitation clinic in Athens.

specialised care often inaccessible on theislands. MSF has treated hundreds of survivors ofviolence, ill-treatment, and torture, who have notbeen identified by the authorities and have notreceived any support. Instead, they have beenplaced in conditions that are not only unsafe but
re-traumatising.
Children seeking mental health support often
display trauma- and fear-induced symptoms
triggered by their environment in the hotspots.
There are alarmingly high rates of self-harming
and suicidal acts among children; the youngest
seen by MSF was six years old. As people’s senseof hopelessness intensifies, their mental healthstate worsens; MSF has documented this in
similar contexts around the world.4
The living conditions in the RICs expose children
to unhealthy and unsafe environments. Between
2018 and 2020, MSF conducted over 42,000
paediatric consultations at its clinic near theMoria RIC, which included treating children for
injuries and burns from accidents, hazards, andviolence. The most common issues were linked
to poor sanitation and exposure to cold weather.
Europe’s leaders have continued to prioritisecontainment and deterrence above the provisionof basic essential services such as water,
sanitation and access to health. MSF and otherNGOs have continuously stepped in to provide
crucial services. From 2019 to May 2021, MSF hastrucked in over 43 million litres of safe water for
people in the over-capacity Vathy RIC, where thewater is unsafe to drink.

Key findings: The Human Cost of Containment
People seeking protection in Europe havealready been exposed to violence and hardship,
and the hotspots are neither safe nor healthy
places for them. The majority of people treatedby MSF have experienced one or more traumatic
events in their country of origin and during theirmigration journey. This trauma is compounded There are significant gaps in access to adequate
by their containment and the everyday structural and timely healthcare for people held on theviolenceI of life in the hotspots. As a result, MSF Greek islands. This may lead to otherwise
teams on the Greek islands respond to alarming manageable medical and mental healthlevels of mental health suffering. Between 2019 conditions deteriorating, becoming more severe
and 2020, MSF mental health clinics on Chios, and potentially chronic. The COVID-19 pandemic
Lesvos, and Samos treated 1,369 patients.
should have been the final straw to abandon
cramped hotspots. Instead, the pandemic has
Major stressors for patients’ mental health amplified the suffering of migrants subjected toincluded navigating daily life in poor living a chaotic COVID-19 outbreak response and harshconditions and unclear administrative procedures, lockdowns in poor living conditions, with little toexposure to violence and insecurity, unaddressed no access to water, hygiene, or essential services.
medical needs, and fear of deportation. Many Measures taken have dangerously conflated
require treatment for post-traumatic stress public health and migration control agendas.
disorder, moderate to severe depression, reactive
psychosis, and anxiety, all of which are serious The hotspot approach harms people’s dignity,
mental health conditions that demand long-term, health, and well-being and is designed as a
I

Structural violence refers to the social structures or institutions that put individuals and populations in harm’s way|2

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

deterrent to those who dare to seek safety There is a vacuum of accountability, enabled
in Europe. This report’s detailed analysis by the EU-Turkey Statement and the hotspot
demonstrates how indefinite containment, model, which has blurred informal agreements,
appalling reception conditions, expanding legal frameworks and responsibilities between
detention, violent border controls and push- national governments and EU institutions. The
backsII, and rapid border procedures work as European Commission, European member statesa system that inflicts misery and puts lives in and Greek authorities must take responsibility.
danger.
Rather than pursuing a brutal, inhumane systemand deadly chaos, Europe must instead adopt
Moving Forward: EU Intensifies a Dangerous
policies that protect human lives and do not
Approachjeopardise people’s health and well-being.
MSF is extremely concerned about the humancost of the MPRICs. Continuing and intensifying
this policy of violence will cause a worsening Key Recommendations :health and protection crisis. The new facilities − Evacuate people from the island hotspots
to safety on the Greek mainland and in otherwill be in isolated and remote areas of the islands.
European states.
People will be held in shipping containers,
surrounded by high, barbed wire fences, with − End the policies of containment anddeterrence, and immediately halt thecontrolled entry and exit. This cannot be sold ascreation of the Greek island MPRICS. The
an improvement in people’s living conditions.
only purpose of centres on the Greek islands
must be the provision of urgent assistance,
The right to asylum is also in jeopardy. The newfacilitation of access to protection andpre-entry border screening regulation (proposed
relocation to safe reception.
in the PACT), together with separate pre-removal
detention facilities inside the MPRICs, will lead − Ensure access to quality, timely medicalcare, tailored to the medical and mental
to widespread deprivation of liberty and thehealth needs of the population, and provided
potential for mass deportations of people seeking
sustainably within the public health system.
international protection. Increased security,−
Invest in a dignified reception system andsurveillance and segregation from the rest ofsafe accommodation for asylum seekers,
society will limit access to services and remove
refugees and migrants, such as housing
any agency or semblance of a ‘normal’ life. An
within communities, as well as integration
anticipated decrease in NGO presence means that
programmes for refugees.
the MPRICs will make people’s suffering moreinvisible and further isolate the most vulnerable. − Establish a fair and transparent asylum
process that upholds all necessary procedural
safeguards and does not violate the rights ofCall to Action
asylum seekers through border procedures.
“I want Europe to notice, to take care of− Ensure no refoulement, violence and death
refugees, to see their problems. We are humanat EU borders: end the violence and pushbeings, we are human beings, like you. As webacks and stop criminalising humanitariansee each other. They cannot leave us in theseassistance. Instead provide safe passage forconditions.”
those seeking safety in Europe. Alongside
Menele, 30 years old in Samos, from
this, invest in family reunification, refugee
Democratic Republic of Congo
resettlement, humanitarian visa and othercomplementary protection pathways, as well
For European leaders, creating the illusion
pathways for work and study.
that migration can and must be stopped ismore important than the safety of people andtheir potential contributions to society throughconsistent reception and integration programmes.
Europe’s dangerous approach to migration isthe cause of the medical humanitarian crisis
in Greece. Demonising and degrading people
seeking safety in Europe is not a solution, but the
problem itself.
II Pushbacks refer to informal and illegal cross-border expulsion of people by States.

The EU plan to intensify its dangerous hotspot approach on Greek islands

3|Introduction

This report details the devastating health andprotection crises that has been unfolding in the
Greek island hotspots since the EU-Turkey Deal.
The hotspot approach implemented which has
resulted in indefinite containment and increased
forms of detention, erosion of protections andthe asylum process, limited access to care andservices, and exposure to appalling conditions,works as a system that has jeopardised people’s
health, well-being and dignity.
MSF warns against the replication andintensification of this dangerous model with the
Migration Pact proposals and new MPRICs.
Key Figures
More than 180,000 people passed
through Greek islands since EU-Turkey
deal (march 2016)847 people have gone missing or deadon the journey to Greece since 2016
At least 21 people died in hotspots
12 fires on Lesvos and Samos leading toinjuries, death and displacement
Source: UNHCR, see annex

Methodology
The report analysis is based on routine patient
data collected in MSF clinical health databasein MSF mental health, child health and medical
programs for survivors of sexual violence on
Lesvos, Samos and Chios islands. This database
was modelled on the standard MSF healthdatabase, and then adapted to capture specificvariables within each context and project. As aresult, there may be some differences between
the information available for each project.

|4

The medical information used in this report iscomplemented by an analysis of information
gathered by the MSF case management teamand legal aid partner on Lesvos, Refugee Support
Aegean (RSA) and PROASYL. All data in this reportcomplies with MSF’s data collection policy, in fullrespect of medical confidentiality.
Testimonies were collected from MSF patientsand staff to complement the quantitative data
found in the clinical health database and support
the analysis in this report. Twenty-five semistructured interviews were conducted with MSF
patients and staff between February and March
2021. They focused on the health conditionsof asylum seekers and refugees, and theirexperiences living in the hotspots and copingwith the administrative procedures. Interviews
were carried out in English or the interviewee’s
native language, and all people interviewed gave
informed verbal or written consent. The namesof patients have been changed to protect theirprivacy.
This report provides a descriptive analysis of thehealth outcomes and the impact of the hotspot
approach on the well-being of men, women andchildren trapped on the island. The health needson the Greek Islands exceed the availability ofservices on the islands and of MSF interventions.
Consequently, the data in this report does not
represent the overall scale of health needs in
Lesvos, Samos and Chios; instead, it provides analarming insight into the severity and range ofthe most visible and critical health suffering on
the islands.

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

The EU hotspot: containment strategy on the Greek islands
The ‘hotspot approach’ was first introduced
in June 2015 by the European Commission in
the European Agenda on Migration and waspresented as a temporary measure to deal
with large numbers of people entering Europe,
facilitate relocation of recognised asylum seekers
and prevent secondary movements to other EU
countries5. It was presented as a solution to themigration reception crisis and five hotspots werebuilt on the Greek Islands, the largest was theMoria Reception and Identification Centre (RIC)on Lesvos.
After the EU-Turkey Statement in March 2016,the hotspots became de-facto containment
centres on the Greek Islands to implement thefast track and return procedures and limit the
movement of new arrivals to Greek Islands.
The ultra-rapid hotspot procedure examines
the admissibility of the claims according to theconcepts of ‘safe third country’ and ‘safe countryof origin’, without need to assess each individual
application for international protection and isdesigned to be concluded in only a few days. In
practice, this approach has demonstrated several
challenges in terms of access to a fair, transparent
and dignified procedure.
Over the years there have been systemic
shortcomings in terms of protection and access toessential services such as running water, shelterand basic health care, despite the full operational
support of EU and its agencies such as FRONTEX(European Border and Coast Guard Agency) andEuropean Asylum Support Organisation (EASO).
EU agencies work hand in hand with national
authorities to conduct border patrols, registrationand nationality assessments, fingerprinting andsecurity screening, eligibility and admissibility
interviews as part of the fast-track borderprocedures in Greece, and deportations. Whilst
the role of the agencies is outlined in theoperational agreements, in practice there is often
blurred accountability and functions between EU
and Greek authorities, frequently resulting in alack of transparency.

Moria Hotspot, Lesvos, March 2017, © MSF

The EU plan to intensify its dangerous hotspot approach on Greek islands

5|were evacuated from the Greek Islands and themainland to other EU countries.7 However, due toa lack of agreement between EU member states
more comprehensive relocation and protection
pathways are increasingly conditional uponincreased control, restrictions at the border anddeportation of migrants.
New centers, same approach:Multi-Purpose RICs
Plans to create five multi-purpose reception andidentification centres (MPRICs) on the Greek
island hotspots are proceeding. These have beenreferred
to as ‘closed’ or ‘controlled’ camps by
Living conditions in the “jungle” area outside Vathy
Greek
authorities.
On 29 April 2021, Commissioner
Hotspot, Samos, February 2019, ©: ANNA PANTELIA/MSF
Johansson visited Lesvos and Samos to promote
Meanwhile, so called solidarity mechanisms the new multi-purpose centres. She toured the
between EU member states such as relocation newly constructed MPRIC on Samos, built using
scheme, which aimed to relocate 160,000 asylum EU funds, which may be operational by June 2021.
seekers from Italy and Greece to other EU It will have capacity to hold around 3,000 people
Member states have fallen short. Less than 20 % and will be jointly operated by EU agencies andof this target was met when the relocation scheme the Greek authorities. At the same time, a joint
was abandoned in September 2017.6 Recognised pilot is taking place on Lesvos, supervised by arefugees and people identified as vulnerable taskforce of the European Commission General
were transferred to mainland Greece, where Directorate for Home Affairs (DG-Home) working
there is a significant shortcoming regarding with the Greek authorities, to establish andaccess to safe accommodation and healthcare. operate a new MPRIC on the island. According
While there have been some ad-hoc agreements to the Memorandum of Understanding (MoU)
on relocation since 2017, these remain voluntary, between the European Commission and the Greek
inadequate, and highly contested between EU authorities, the MPRIC will have the capacity toStates. Between 2020 – January 2021, 2,296 hold 5,000 people and is initially planned to bepeople including, unaccompanied minors ready by September 2021.8
and sick children with their family members

LESVOS
CHIOS
SAMOS
LEROS
KOS

|6

Location 9

Name of
Capacity
Reception and
Identification
CentreDetention
Capacity
inside theRIC

LESVOS

Moria RIC

2,757

210

CHIOS

Vial RIC

1,014

0

SAMOS

Vathy RIC

648

0

LEROS

Leros RIC

860

0

KOS

Pyli RIC

816

474

–

6,095

684

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

The Human Cost of Containment

MSF provides medical humanitarian support on
Lesvos and Samos islands. We previously also ran
a project on Chios, which closed in December 2019.
MSF offers holistic medical care, including mental
healthcare, sexual and reproductive healthcare,vaccinations, as well as social and legal support
to people living in the hotspots. MSF mental
health projects on Lesvos, have a special focus
on children and survivors of violence including
survivors of torture and ill-treatment. MSF
receives referrals from medical organisations
working in the RICs, which have limited capacity
to provide mental health care and medical
assistance to people with severe mental healthconditions.
MSF also covers the cost of appointments withprivate specialists and medication for patients
who do not have official access to healthcare. In
July 2019, the Greek government revoked accessto public healthcare for asylum seekers, leaving
thousands of people deprived of regular accessto care, until it was formally partially restored in
November 2019 through the introduction of a newregistration number called ‘temporary insurance
and healthcare number for foreigners’, otherwise
known as PAAYPA. However, many asylum seekers
remain unregistered due to administrative delays.
Graph 1: Breakdown of patient per mental healthproject (2019-2020)
Chios
Mental Health Activites

191

Samos
Mental Health Activities

286

Mytilene
Mental Health Clinic
Lesvos376

Moria Childern and Family
Mental Health Activites
Lesvos516

MSF teams on the Greek Islands are responding
to an acute level of mental health suffering,that is compounded by the containment andeveryday structural violence of the hotspot.
Between 2019 and 2020, MSF mental healthprojects on Chios, Lesvos and Samos treated 1,369
patients, of which one-third (465) were children
and 5 per cent were under the age of five. The
youngest was only one year old. More than 40 per
cent of patients were female. Most of the patients
who sought out mental health services from MSF
were from Afghanistan, Democratic Republic ofCongo, Cameroon and Syria.
Graph 2: Breakdown of age and gender of total
number of patients attending mental health projects(2019-2020)

Female43%

Under 55%Child
(5-18)
29%

Male
56%

Adult
62%

Other
1%

Unregisterd
4%

Importantly, among MSF patients there areseveral people identified as survivors of tortureor severe violence from countries including
Ghana, Togo, Senegal and Gambia. Since 2020,
these countries were among a list of 12 countries
designated as ‘safe’ on Greek government’s socalled ‘safe countries list’.10 According to recent
legal reforms in the International Protection Act,
all applicants coming from a safe third country
and a safe country of origin are to be subjectedto the fast-track border procedure which
provides them with much fewer safeguards andprotections.11

The EU plan to intensify its dangerous hotspot approach on Greek islands

7|Graph 3: Breakdown of nationalities of MSF patients
attending mental health projects (2019-2020)
Gambia 2%
Palestine 2%
Congo 2%Guinea 2%
Togo 2%Ghana 3%

DRC
23%

Other
11%

Iran 4%
Sierra Leone
4%

Afghanistan
16%

Iraq 4%
Syria
11%

Cameroon
14%

People arriving to Europe’s shores to seek
protection have already been exposed toviolence. Most people treated by MSF reported
one or more traumatic events in their country oforigin and/or during their migration journey. Many
MSF patients in mental health projects reportexperiencing torture, violence and ill-treatment
including forms of psychological violence such as
threats, harassments and humiliation, bombing
and shelling, incarceration, shipwrecks andviolent push-backs, and persecution due to theirrace, ethnicity, sexuality and gender identities.
The hotspots are not safe places for people
seeking asylum. Patients reported facing
challenging situations in Greece that likely
exacerbated their feelings of vulnerability andtheir mental health problems. This included
sexual violence, detention, physical violence
and ill-treatment from community members
and state authorities and receiving racist abuse.
A recurrent theme that emerged from themental health consultations was the sense ofhopelessness that people felt as a result of having
no control over their lives or their futures.

Mental health deterioration among
adultsAmong the 845 adult patients admitted to the
MSF mental health clinics in Chios, Lesvos andSamos. More than 35 % were diagnosed with posttraumatic stress disorder (PTSD), a psychologicalresponse caused by experiencing or witnessing ahighly traumatic event, such as severe violenceor threats of violence, war, a natural disasteror a severe injury. Symptoms of PTSD often
include flashbacks, nightmares, irritability|8and hypervigilance and can negatively impact
concentration, memory and daily functioning.
The second highest diagnosis was moderate
to severe depression (17 %), followed by acute
psychosis (12 %) and anxiety (3 %). The mostcommon symptoms were recurring nightmares
and sleep disturbances, panic attacks, severe
depressive symptoms and psychotic symptoms
such as hallucinations, delusions, withdrawal andmutism. Patients also presented with physicalsymptoms, including chronic headaches, digestive
problems and chronic pain, especially in theirback. All the mental health conditions treated by
MSF are serious conditions with that may requirelong-term, specialised care. However, suchtreatment is not accessible to people containedon the Greek islands.
Graph 4: Mental health diagnoses among patients in
Mytilene clinic on Lesvos, Samos and Chios mental
health projects (2019-2020)
PTSD
Moderate/
Severe Depression
Acute Psychosis
Suicide Attempts
and Self-harmAnxiety
Adjustment Disorder

293 35%145 17%101 12%
64 7%
29 3%
26 3%
17 2%

Grief
Chronic Psychosis

12 1%
11 1%

Acute Stress
Other
No Diagnosis

36 4%
0

50

73 9%
100 150 200 250 300

MSF teams responded to over 50 adults who had
attempted suicide while on the Greek islands.
More than two-thirds of the patients who had
attempted suicide demonstrated symptoms of
PTSD. Research shows that PTSD and depression
are associated with increased rates of suicidal
ideation and attempted suicide, especially among
asylum seekers and refugees.12
Main issues impacting mental health patients:− Stress and insecurity linked to living conditions in the RIC− Past traumatic experiences, especially violence related− Anxiety and fears related to the asylum procedure, detention or deportation− Unaddressed medical concerns− Death or Separation of Family Members

CONSTRUCTING CRISIS AT EUROPE’S BORDERSMSF staff care for a woman injured after a fire that destroyed Moria hotspot, Lesvos, September 2020, © MSF

Their containment in the hotspots often further
damages the mental health of people on the Greek Greece limits the recognition of vulnerable
islands. Continuous traumatic stress (CTS) refers people: The exclusion of PTSD in theto the psychological impact of living in conditions International Protection Act
in which there is a realistic threat of present and The International Protection Act, passed by the
future danger. Research on CTS suggests that Greek government in 2019, further limited theprolonged exposure to trauma may increase the vulnerabilities that they are required to provide
severity of psychological disorders, especially additional protections and support for durover the long term13. Among MSF patients, daily ing asylum procedures. The new law removed
stresses and constant fears were raised as major PTSD and survivors of shipwrecks from the list
factors impacting their well-being and mental of vulnerabilities (art. 58).14 This change in thehealth. This included navigating daily life in poor law follows several years of attempts by authoriRIC conditions and complicated administrative ties to reduce the number of vulnerable people
procedures, exposure to violence and insecurity, identified in the RICs.15 The arbitrary removal offamily separation, unaddressed medical needs, PTSD disregards the seriousness of this mental
and fear of deportation. This continuous health condition and reduces the likelihood ofstress prevents people from developing coping early intervention and protection for vulnerable
traumatised people. Research has demonstrated
mechanisms or building resilience.
that asylum interviews may exacerbate posttraumatic symptoms, especially among asylum“This place destroyed me from the inside. I am
seekers who received no preparation or psychoafraid, and I have a lot of stress. In the night,
logical support during their procedure16.
a shadow comes for me. I am broken frominside. The best way to describe the situation
here on Lesvos is ‘dying without ending’.”
Mohammed, 30 years old in Lesvos, fromAfghanistan

The EU plan to intensify its dangerous hotspot approach on Greek islands

9|Children at risk: mental health
In MSF’s paediatric health projects on Lesvos, wehave cared for an alarming number of children
with deteriorating mental health. Between 2019and 2020, MSF treated 456 children on Lesvos
with mental health problems, including 32
unaccompanied minors.
These children displayed trauma and fearinduced symptoms, often triggered by their lives
in the hotspot. The main symptoms included:
sleep disturbance and nightmares (39 %),generalised fear (24 %), behavioural regression
and development delays (30 %), helplessness
and detachment (25 %), and psychosomatic
complaints, such as headaches, stomach aches
and dizziness (10%). This often resulted in children
experiencing impaired concentration, learning,interaction and play, lack of verbalisation or
accident-prone behaviours, bed-wetting, andinability to control negative emotions.
There were alarming high rates of self-harm andsuicidal acts among children. Out of the 180 MSF
patients who had experienced self-harm, suicidal
ideation or had attempted suicide, more than twothirds were children; the youngest of which was a
six-year-old child. Among the 32 unaccompanied
children treated in the paediatric clinic, 20 per
cent had engaged in self-harming behaviour
and 15 per cent had experienced suicidal
ideation. MSF staff observed that the significant
rates of suicidal thoughts and self-harming
as an unfortunate consequence of an unsafe
environment, extended limbo and uncertainty.
As people’s sense of hopelessness increases,
their mental health worsens; MSF projects indetention and containment settings, such as on
the island of Nauru, have found similarly highrates of suicide.17

A young girl plays in the “Olive Grove”, overflow of Moria
hotspot, Lesvos, February 2019, © ANNA PANTELIA/MSF|10Graph 7: Most common mental health symptoms
among patients attending the Moria Paediatric Clinic(2019-2020)
Sleep Disturbances
Generalised Fear
AggressivenessHelplessness and Passivity
Detachment, Isolation
Specific Fears
Self - Harm
Altered Behavior
Somatic Complains
Bed-wetting and uriantion
Suicidial Ideation
PTSD Signs
Anxious Attachment
Panic Attack
Depressive Signs
Impaired Concentration and Learning
Abrupt shifts in relationships
Lack of Verbalisation
Eating Disturbance
Other
Regressive Symptoms
Suicidial Attempt
Psychosis Signs
Anxiety136 24%142 25%64 11%
76 14%
70 12%
82 15%
34 6%
57 10%
27 5%
43 8%
18 3%
18 3%
18 3%
29 5%
15 3%
16 3%
12 2%
24 4%
21 4%
21 4%
16 3%
8 1%
16 3%
0
50
100 150

219 39%200

250“The main reason that children become ill isthat most them are already traumatised in
the first place. They are traumatised in theircountry of origin, then during their travel
here and then in Moria. It is either fights,
stabbings or police violence, and of course
also the fire severely traumatised them. What
the brain needs is stability, safety and predictability, and none of these are present. They
weren’t there in the old Moria and they are
not in the new camp either.”
Katrin Brubakk, child psychologist for MSF
in Lesvos.
There were often spikes among children after
emergencies or violent incidents in the hotspot.
For example, after the stabbing of a 15-year-old boy
in the unaccompanied minors’ safe section of theMoria RIC in August 2019, MSF teams responded
to six acute mental health emergencies amongchildren living in the section in four days. These
included self-harm, severe anxiety attacks andflashbacks, mutism and risk-taking behaviour.
Based on staff observations, mental healthconditions among children worsen the longer
they stay in the camps and have significant impact
on the entire family and the broader community

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

in the RICs. MSF conducts group sessions withparents and families to address children’s fears
and anxiety, to help them support the well-beingof their children, and to help build their children’s
resilience.
‘My daughter says she does not feel safe. Aftera fire in the camp, she was traumatised alot. My daughter is six years old. When wearrived here, her weight was 24 kilos, andnow she is 16 kilos. She does not eat and haschanged so much, she was a calm girl, but
now she is always afraid. She is even afraidof the sound of raindrops when she is inside
the tent. The hardest part for me is I see mygirl getting worse day by day, and I cannot
do anything. All I want is a safe and secure
place for my child to have a future like otherchildren’Fatima, 33 years old in Samos, fromAfghanistan

Children at risk: physical health andwell-being
The living conditions in the RICs have severely
affected the physical health and well-being ofchildren. Between 2018 and 2020, MSF conducted
over 42,000 paediatric consultations at its clinic
near the Moria RIC. More than 20,400 were forchildren under the age of five, and 850 were withunaccompanied minors. The most common issues
were upper and lower respiratory tract infections(33 %), skin infections, including scabies, lice
and chickenpox (20 %), and gastrointestinal
conditions (19 %), including watery and bloody
diarrhoea. These issues are often linked to poor
sanitation and exposure to cold weather. MSF
treated children for injuries, wounds and burns(5 % of consultations) often from accidents andhazards around the RIC, and those resulting fromphysical and sexual violence.
Between March 2019 and November 2020, MSF
treated 320 children and adolescents with chronic
and complex conditions, including heart disease,diabetes, epilepsy, Down’s syndrome and asthma.
Children held in the hotspots often do not haveaccess to timely treatment, medication, tests
and follow-up care. The lack of access to care,combined with the hazardous living conditions,
may led to long-term negative impacts on thesechildren’s physical health. As a result of successful
advocacy efforts by MSF and other NGOs, most ofthese children have now been relocated to otherEU member states.

Sexual violence and a chronic lack ofprotection
MSF receives a high number of reports of sexual
violence and harassment across the hotspots,
where, risk reduction and response measuresremain grossly inadequate. Instances of sexualand gender-based violence (SGBV) are known
to increase in a more stressful environment; theviolence in and around the RICs is compoundedby lack of safety and protection measures. People
report to MSF that they are afraid to leave their
shelter or wait in the food lines. Toilets andshowers remain dimly lit, resulting in people
fearing going to the toilets or taking a shower inthe evening and early morning hours. Female
patients report bathing inside their tents andavoiding drinking later than the early afternoon
to minimise the need to leave their shelter atnight. However, daytime does not necessarily
offer protection; MSF previously treated a child
who was sexually abused in the toilet during theday. In addition, the hours long queues to receive
food rations leaves vulnerable dependents alone
in their shelters and exposed to assaults.
Since 2019, MSF has treated 325 survivors of
sexual violence on Samos, Lesvos and Chios.III
Among them have been women who are travellingalone, pregnant women, people who identify as
LGBTQI+, unaccompanied minors and people
with disabilities.
On Lesvos, of the 186 patients treated, a quarterhad experienced sexual violence inside the Moria
RIC.
Survivors often feel afraid to report sexual
violence to the authorities and even when they
do they are sent back to the hotspot in which
it occurred. In practice, survivors of sexual
violence are often obliged to report the incident
to police to gain access to emergency healthcare
and protection. As a result, some cases lose
the limit of 72 hours for emergency treatment
such as post exposure prophylaxis, which
offers protection from pregnancy and HIV. For
survivors that decide to proceed with reporting

III This is the number of people who have sought care with MSF and is not representative of the total number of people who haveexperienced sexual and gender-based violence, which is known to be under-reported.

The EU plan to intensify its dangerous hotspot approach on Greek islands

11|our teams have witnessed severe shortcomings
and re-traumatisation throughout the procedure.

of culturally acceptable family planning methods,
and responses to outbreaks of disease.

“I had a girlfriend; she was coming to my tent
to see me. One day a guy stormed into the tent
and beat us up. We were very afraid to be seen
together. One day we decided to meet near thepolice, so we if something happened the police
could come to intervene but as we were going
there, I felt someone grab me around the neckand punch me in the face. I turned and saw
also somebody else beating up my girlfriend.”
Neta, 25-year-old woman in Samos, from
Democratic Republic of Congo

To address this gap, MSF has conducted massvaccination campaigns in Chios, Samos, Lesvos,
Leros, and Kos between 2017-2019 to ensurechildren are protected from preventable lifethreatening disease such as tetanus, measles,and diphtheria and continue to provide routine
vaccinations for children and new-borns in our
projects in Lesvos and Samos. Between 2018March 2021, MSF has administered more than
25,000 vaccine doses on Levos and Samos. Due togaps in the provision of sexual and reproductive
healthcare MSF provides these services for thoseOn the islands, there are limited options for safe living in the hotspots. On Lesvos, Samos andand appropriate alternative accommodation for Chios between 2018 and 2020 MSF provided
vulnerable people. Between February and July 5,050 antenatal consultations, 815 post-natal
2020, only 11 of the 26 survivors of SGBV that consultations, 1495 family planning consultations,
MSF referred for safe shelter on Samos were as well as 2,217 gynaecology consultations,granted a space. In December 2020 the ESTIA with referrals to the hospital for emergency or
shelter programme on Samos closed. On Lesvos, secondary care.
the Greek government has closed alternative
accommodations such as PIKPA and Kara Tepe, Local health services and hospitals on thewhich were providing safe accommodation, and islands are not equipped to deal with the
moved the vulnerable people who were residing additional pressure of the hotspots and often
there to Mavrovouni camp, where they lack the lack the specialists needed to treat the complex
necessary support and protection.
conditions, which asylum seekers suffer from,and the cultural mediation skills to help them
Systematic gaps in healthcare
access care. The gap is particularly devastating
for people with psychiatric conditions who need
There are significant systematic and structural specialised treatment and accommodation. In
gaps in the provision of essential and urgent March 2021, the standing committee for the rights
healthcare for asylum seekers, refugees, and of persons with mental health conditions undermigrants on the Greek islands. Since the the Greek Ministry of Health reported the severe
implementation of the EU-Turkey Statement, shortcomings in appropriate mental healthhealthcare provision is heavily dependent on provision for people with severe mental healththe support of NGOs and volunteer-run medical symptoms in the hotspots18. The alternative
organisations. Meanwhile, the official medical accommodation programme for vulnerable
unit in the hotspot, which is currently EODY (The asylum seekers, ESTIA, is often unable to hostNational Organisation for Public Health), has people with acute psychiatric symptoms due tobeen diverted to the vulnerabilityIV screening for the specialised care they require. This further
the fast track border procedure. This diversion of highlights the need for alternative and specialised
health actors to the border procedure combined types of reception-based accommodation at a timewith a continual lack of sufficient staff and when the Greek government seems determinedresources has resulted in systemic deficiencies in to prioritise the closure of existing ones.
the overall health response. This is demonstrated
in severe shortcomings in providing preventative MSF continues to call for the evacuation of allcare, such as routine vaccinations, incorporation people with medical conditions that require
medical care not available on the islands.
IV The term ‘vulnerability’ in Greek and EU law focuses on specific categories, including victims of torture, children, pregnant women,elderly, victims of trafficking etc. to highlight the need for special protections (procedural guarantees and special reception
conditions). MSF preserves that migrants are not inherently vulnerable nor do they lack agency, instead migrant vulnerability arises
from multiple and intersecting forms of discrimination, inequality and structural dynamics that leads to diminished enjoymentof rights and places people at risk. Migrants may find themselves in vulnerable situations as a result of their reason to flee,
circumstance of travel and conditions they face on arrival, or because of personal identities.

|12

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

The COVID-19 effect: conflation of publichealth and migration control
The COVID-19 pandemic has amplified thesuffering of migrants and has exposed theirstructural exclusion. MSF has called for the
inclusion of asylum seekers, refugees andmigrants in the COVID-19 response and offeredsupport. In absence of any appropriate publichealth response MSF provided health promotion,
infection and prevention control trainings anddignified isolation for suspect or confirmed caseson LesvosV, while on Samos we provided earlycase detection and awareness.
The lockdown measures and movement
restrictions applied to people in camps andrefugee facilities on both the islands andmainland were stricter and applied for a longer
duration than those applied to the rest of Greece.
People in the hotspots were subjected to monthsof lockdown in poor, crowded living conditions,with derisory access to water and toilets, limitedaccess to healthcare and an inadequate COVID-19
outbreak response. Asylum procedures weresuspended throughout the lockdown leaving
people in limbo. All of this led to a deteriorationof mental health in the RICs and often placed
detainees at greater risk of contracting COVID-19
or other illness.
These measures conflated public health witha migration control agenda. The COVID-19
restrictions provided a glimpse of how the
MPRICs could lead to complete and arbitrary
control over the camp populations’ movements.

confined in the Megala Therma quarantine site,
often for weeks at a time, in grossly undignified
and inhumane conditions. Our teams provide
general healthcare on-site once a week. They havewitnessed a very serious and systematic neglect
in the provision of essential services, protection
and proper access to specialist healthcare. There
have also been deeply concerning allegations ofasylum seekers being taken from Melaga Therma
and returned to Turkey19.
“For one month we had no toilet, no electricity,
nothing […]. They didn’t explain to us why
we were there. They just told us that weneeded to remain there, and they would cometo do a coronavirus test. That’s all. They told
us that we were going to stay there for two
weeks when they would do the first COVID-19
test. After two weeks they came again to do
the COVID-19 test and then we stayed again
for two more weeks.”
Abdullah 30-year-old in Lesvos from Togo
Since January 2021, MSF advocated for the urgent
removal of 25 patients from the site, including
babies with serious medical conditions; heavily
pregnant women in need of antenatal care;survivors of torture and ill-treatment withserious mental health conditions, including
PTSD and suicidal thoughts; persons withdisabilities or other serious medical conditions;and unaccompanied children in need of urgent
follow-up care and medical treatment. Out of thisgroup, only seven people were transferred out of
the site in a timely manner.

“After COVID [the first lockdown], the situation became worse. The police became very
strict, stopping people in the camp, not letting
anyone out of the camp. We were alreadysuffering in the camp… and being forced tostay in the camp we were badly affected. […]There is a huge difference between COVID forthe refugees and COVID for the locals because
the refugees had more pressure and more
restrictions compared to the locals.”Ali, 32 years old in Samos, from Syria
The designated COVID-19 quarantine sites for new
arrivals have become de-facto detention centres.
As of mid-January 2021, more than 500 people
arriving to the north coast of Lesvos have been

An MSF health worker examines a young patient whilst
wearing full PPE, May 2020, © ANNA PANTELIA/ MSF

V MSF was forced to close the COVID-19 isolation centre set up on the island of Lesbos, Greece on 31st July 2020 due to administrativefines and potential criminal charges, related to urban planning regulations.

The EU plan to intensify its dangerous hotspot approach on Greek islands

13|

The ‘Shield’ of Europe:
Normalisation of Push-backs
and Violence at Borders
To tightly control the number of migrants
arriving in Europe, the European Union and its
member states have reinforced the militarisationof both their land and sea borders. This has led to
the widespread use of violent tactics, push-backs
and the illegal forced return of asylum seekers
to unsafe countries (known as ‘refoulement’),
in which EU borders guards, coastguards and
FRONTEX forces are allegedly implicated.
Recent reports have found that EU member states
have used illegal operations to push-back at least
40,000 asylum seekers from Europe’s borders
during the pandemic, using methods that arelinked to the death of more than 2,000 people20.
Between 2016- 2020 MSF projects in the Serbia
and Bosnia and Herzegovina, have treated at least
940 people that have been victims of violence at
EU borders along Balkan Route. More than 60 per
cent of patients report the alleged perpetrators
as border authorities from EU member states,
including Croatia, Hungary and Romania.21
In early March 2020, the European Commission
President Ursula Von der Leyen praised Greece
as the “shield” of Europe, after a concerning
number of reports and allegations of illegal
push-backs at Greece’s land and sea borders, inwhich FRONTEX, and the Greek military andcoastguard were all implicated22. MEPs on the
EU civil liberties committee23 and Commissioner
Johansson24 have called for an investigation
into the allegations of push-backs at the Greek–
Turkish border. In January 2021, the EU antifraud office launched a probe into FRONTEX25
over allegations of harassment, misconduct
and unlawful operations to stop migrants fromreaching EU borders.

|14

In recent months, people arriving on the Greek
islands have told MSF about the violent practices
employed at the sea border. These include making
waves around the inflatable boats, assaults bygroups of masked men, the use of guns and otherforms of violence. No one is spared; pregnant
women, children and people with disabilities
have all been targeted.
“I was pregnant, but I had a miscarriage
because it was very hard, and I had a lot ofpressure on me. […] Every time we attempted
to cross the sea border to come to Samosthe coastguard boats made high waves andtried to pull us back to Turkey... It was hardfor children; hard for us and harder for mychildren.”
Fatima, 33 years old, in Samos fromAfghanistan“They have those boats; they catch you andthen they leave you in the middle of the sea.
You have no protection. They will remove
everything, even if you have a jacket, they
will take it from you. They will take yourmoney, your telephone. If you have anythingthat you have of value, they will take it fromyou. They take from the people and leave youin the middle of the sea.”
Abdulrahim, in Lesvos

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

An inflatable boat carrying 45 people off the coast of Lesvos, December 2015, © WILL ROSE

From March 2020, MSF documented several
testimonies from patients describing escalating
push-back tactics. After they reached the Samos
RIC in September 2020, two minors were takenfrom the island, put back in a boat and left adrift
at sea26. Similarly, after landing on Lesvos in
March 2021, a father, mother and their two young
children were driven in a van to the coast, beaten
by masked men and left adrift in a raft27. We haveheard of other similar cases, including 18-yearold Aisha’s account:the small life raft. All 19 of us in one raft. They
pushed us. […] At 11 o’clock in the morning,
the Turkish coastguard saw us... Two people
almost lost their lives; they were not in theirsenses. They rescued us and gave us blankets.
I could not feel my body. I could not feel pain.
Everything just died in my body. Because wewere sitting on top of each other, so I couldn’t
feel any pain.”
Aisha, 18 years old, in Lesvos“They had one guy; he was not wearing a
police uniform, he was dressed normally. He
told us to take our trousers down. He had
gloves on and he search me, around mybreasts, my private parts. He took my phone.
[…] At 10 o’clock at night they brought us toa minibus. They put all of us in there; there
were 19 of us. We drove to a very faraway
place. There, they said, ‘Don’t worry, we aretaking you to Athens for a coronavirus test’. I
said, ‘No’ – I was crying – I said, ‘You are nottaking us to Athens. You want to take us back.’
They told me to ‘Shut up and walk fast’ […]They took us, one by one, and pushed us into

The EU plan to intensify its dangerous hotspot approach on Greek islands

15|

The EU’s Dangerous Hotspot
Experiment

The medical data and analysis from three years
of MSF health projects on Chios, Lesvos andSamos demonstrate the severe impact of thisEU’s hotspot approach on the mental health, wellbeing and protection of people seeking safety inEurope. These are not unintended consequences:the hotspot is designed not only as a facility forprocessing asylum seekers but as a deterrent
to those who dare to seek safety in Europe.
This section will detail the underlying ways inwhich the hotspot approach which includes
the containment, expanding detention, violent
border control and fast-track border procedures
work as a system that inflicts misery and puts
lives in danger.

The everyday violence of containment“For patients in the hotspots, everything ismuch more intense. Acute symptoms areconstantly triggered because of the environment they live in and their traumatic experiences. People must put tremendous effort into
just existing within such an abusive context.
Abuse can be many things. It is not just theviolence in the camp, but that here you must
learn to live in another way. You lose youridentity. Suddenly, you become someone who
waits in lines all day and asks for basic things,
like food, water, shelter and safety, that areoften denied. In our sessions, people often
tell me that they are just there, that there
is nothing left to imagine or dream. They
live with a constant feeling of intense fear;whether in Moria or the new camp, nothing
has changed.”
Zoi Marmouri, MSF psychologist, Lesvos
The impact of the hotspot containment
policy on people’s physical and mental healthis a humanitarian crisis with devastatingconsequences. Since 2016, chronic overcrowding,|16

security issues, and a lack of access to adequate
healthcare, sanitation, and food have contributed
to at least 21 deaths28, including a six-month-old
baby who died of dehydration.
Before September 2020, when Moria RIC wasdestroyed in a fire, it was more than five times
overcapacity. More than 13,000 people lived ina facility built for 2,757. As a result, most people
lived in slum-like conditions in the unofficial
extension of the RIC known as the Olive
Grove, where people had no access to toilets,
showers, electricity, or sewage. In partnershipwith Watershed, MSF installed chemical toilets,
showers, and water points with solar lights
and water heaters in the Olive Grove. This was
required more than five years since creating the
hotspot.
The overcrowding and sanitation situation issimilarly dire on Samos. In September 2020 the
Vathy RIC on Samos was around seven times
overcapacity, with approximately 4,300 people
living in and around a centre meant for 648.29
The water inside the official Vathy RIC is not
safe to drink. Between 2019 and May 2021 MSF
has brought in by truck over 43 million litres ofwater to the population in Vathy camp. MSF has
also installed and maintained 80 toilets per year(in 2019 and 2021) and 68 toilets so far in 2021, as
well as 30 showers and 200 rat traps.
The Mavrovouni temporary facility built
following the destruction of Moria remains well
below adequate standards. Residents continue
to live in a make-shift camp, exposed to harshweather conditions, in a site reported to havelead contamination30. Just like Moria RIC, thesanitation in Mavrovouni is grossly inadequate,
as are its safety precautions.

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

Vathy hotspot, Samos, March 2016, © GUILLAUME BINET/MYOP

Graph 8: Overcrowding in the five hotspots(2018-2021)

The persistent deficiencies in providing
basic reception conditions, coupled with theprocedures in place to implement the EU-Turkey
Statement, are clearly harming people seeking
protection in Europe. According to European
Fundamental Rights Agency, “the processing ofasylum claims in facilities at borders, particularly
when these facilities are in relatively remotelocations, brings along built-in deficiencies
and experience in Greece shows, this approachcreates fundamental rights challenges thatappear almost unsurmountable.”31

6,438

2018

11,375
16,225
6,438

2019

11,375
21,114
6,095

2020

36,34823,746

10,466

Capacity# of People - April# of People - September

40,0002021

20,00013,338The high-security detention-like conditions in
the RICs cannot provide asylum seekers witha safe environment. The highly visible police
presence, the official communications deliveredby loudspeaker, the fencing and razor wire, allserve to worsen the pervasive sense of fear andexacerbate existing vulnerabilities. People lacka sense of privacy, respect, care or dignity, withlong-term consequences for their health andwell-being.

The EU plan to intensify its dangerous hotspot approach on Greek islands

17|

“We saw the camp; we were shocked. It looked
like a prison, not really a camp.”
Ali, 32 years old in Samos from Syria

model. The new centres are more securitisedthan the existing camps and are in more isolatedareas of the islands. This cannot be sold as an
improvement in living conditions.

It is not only living conditions that have an
impact of people’s well-being. A loss of sense of Failure to identify and protect vulnerable
self, uncertainty for their safety and their future, people
and a lack of agency leave people with a senseof hopelessness. This situation, compounded by According to Greek law, people identified
the ever-present threat of deportation, severely as vulnerable are due special protections,
including access to appropriate services, special
impacts their mental health.
reception conditions and adequate support.
“It is a nightmare; it is worse than a nightVulnerability assessments should occur during
mare… Eating, sleeping, having a shower,
the identification procedure upon arrival andunderstanding what is going on with the
involve medical and psychosocial staff in thepaperwork and the asylum procedure. Dogs
RIC33. However, MSF has regularly documented
the failure of the authorities to identify
and cats are more protected than we are…
vulnerable people properly. The ‘swift’ process
Our lives are paused here. We know only theemployed as part of the hotspot model reduces
date we enter. We never know the date wethe chances of identifying vulnerable people orwill leave. We are very tired. I am very tired
those with special needs, especially when thesewaiting here… We came here to seek asylum;
are not easily visible, such as people with mental
this does not mean they have to treat us likehealth conditions or those that have been victims
animals. They should treat us like... we areof violence. Disclosure of traumatic incidents is
also human beings.”
a lengthy process that should be conducted by
Neta, 25 years old in Samos, from Democratic
specialised staff and requires trust-building andRepublic of Congoestablishing a safe environment.
Hostility and increased xenophobia from
“The medical screening is far from adequate,
authorities
andfractions
withinlocal
often they are rushed with the doctor
communities have escalated in recent years.
spending merely half an hour with each
The Greek Government have introduced morepatient […]. A proper psychiatric diagnosis
administrative measures to shirk humanitarian
requires a psychiatrist to observe the patient
space. In October 2020, local organisation Lesvos
over several sessions, build trust and create
Solidarity was forced to close PIKPA, a commun­a safe environment. Here, you have half an
ity run alternative shelter which provided
hour with this person; they’ve been waiting
accommodation for vulnerable people due tofor hours outside, and there are many people
administrative fines and the criminalization ofaround. It’s an environment not fit for identitheir activities32. In February last year, tensions
on the island boiled over after authorities
fying vulnerabilities.”
announced the construction of MPRICs on theGreg Kavarnos, MSF Mental Health
Greek islands, which led to riots, roadblocks,
Supervisor, in Lesvos
arson, and xenophobic attacks on asylum seekers
and those providing them assistance.
The screening process is not adequately designed
to identify vulnerable people in need of protection
Despite years of evidence against this model, or medical follow-up. Instead, the identification
the International Protection Act and the pre- of non-vulnerable people for deportation andentry screening proposal in the EU Migration detention is prioritised. Health authorities view
and Asylum Pact reinforce the containment of people with suspicion and disbelief when seeking
people on the islands and the implementation of assistance, care, and certification of their illness
screening and border procedures for all people, or vulnerability. Recent legal reforms haveincluding vulnerable people, at the edge of the further limited the definition of vulnerability
EU’s borders.
and removed protections for people identified asvulnerable. Before the International Protection
The MPRICs will likely worsen the structural Act, vulnerable people were exempt from theviolence embedded in the existing hotspot fast-track border procedure and would be able

|18

CONSTRUCTING CRISIS AT EUROPE’S BORDERSA young mother and her child look out through a fence at Moria hotspot, Lesvos, May 2018, © ROBIN HAMMOND/WITNESS CHANGE

to have their asylum claims assessed under the
regular asylum procedure on the mainland, but
this is no longer the case.34

screening, the asylum process or how to reachthe hospital. Many people who were injured
were asking for doctors, but they did nothing.”
Abdul-Aziz, 32 years old in Samos, fromAfghanistan

When people seeking asylum first arrive on
one of the Greek islands, they are screened andregistered by the Greek police, with the support Young people are often registered as adultsof FRONTEX. According to patient testimonies, without proper age assessments, in violation
new arrivals are not provided with information of the presumption of minority as enshrined inregarding their rights and protections. Authorities articles 3 and 12 of the Convention of the Rights
put little time and effort into effectively of the Child.
identifying and referring vulnerable people to“When I arrived, I was 17 years old and I had
appropriate services and organisations. Somealready gone through a lot. I didn’t have mypatients reported experiencing dehumanising
passport and they didn’t believe that I was 17.
practices, such as being forced to sit on a cold
When I told them my date of birth, they said
floor while wet, no access to food or blankets, andno because you don’t have any passport[…]police using intimidating and humiliating tactics.
later when I went to the asylum interview, I
told them my date of birth. They told me that
“When we arrived, they brought us to thesince I was registered as an adult in the thepolice station in the camp. They did not tell
first place, they cannot change it.”us anything about the fact that we couldn’t
leave the island. They asked us how we came
Jeremy, 18 years old in Lesvos fromhere. They took all our documents, passports,
Democratic Republic of Congo
everything we had, and then asked us who
High turnover and shortages of key staff, including
was the captain of the boat. They registereddoctors, psychologists, social workers andour names. No one told us about the medical

The EU plan to intensify its dangerous hotspot approach on Greek islands

19|interpreters, has left the screening process withnumerous shortcomings. Medical assessments
are often delayed and some patients reportattending their first asylum interview prior tobeing seen by a doctor.
A lack of access to reliable information andlegal support at this stage in the procedure
creates confusion and uncertainty. Asylum
seekers are not provided with any record of theirvulnerability status or details on the sharing
of information between the reception service
officials and asylum services officials conducting
the border procedure. In 2019 and 2020, MSF
legal partner PROASYL/RSA represented 56 MSF
patients and their family members in attempts torecognise their vulnerable status and ensure they
have access to healthcare and safeguards in theirasylum procedures.
“We have had so many patients who requirecare that is not available on the islands. Everytime, it takes months to prepare and advocate
for their vulnerable status to be identified
and their geographical restrictions to be lifted.
An inhumane bureaucratic system has been
built […], which burdens the already overburdened health system. You need to convince
so many different authorities from the RIC
officials, to the police, EODY and UNHCR tomove one person. It is practically impossible
for asylum seekers to do this by themselves.”
Anna Pavlidi, MSF case manager on Lesvos(2019-2020)

Erosion of asylum: ‘Fast track’procedures and return
Navigating the complicated and constantly
changing border and asylum procedures can bea nightmare for people seeking safety in Europe.
Uncertainty, fear and confusion regarding theprocedures were one of the main causes ofstress for people treated by MSF. The fast-track
procedures implemented on the Greek Islands
aim to quickly determine whether a person can
begin their asylum procedure or be immediately
marked for return, often based on people
country of origin rather than the individual
circumstances of their claim for protection. This
procedure has changed many times throughout
the years and faced periods of extreme delays
followed by periods of acceleration. While a swift
process that does not leave people living in a state|20of limbo is welcome, over the years, this process
has not proven to be fair, dignified, transparent
or accompanied by the appropriate support.35“After two weeks I had the big interview… I
was not well. They didn’t ask me about thepain that I was feeling. I had just arrived; I
was not thinking clearly. I was not able tosleep, and I had a lot of nightmares duringthat period. My friend took me to EASO… I
showed them my prescription. I told themthat I didn’t feel well. They asked me if I can
express myself and I told them I would try. I
have just received my result, a negative.”
Adam, 35 years old in Lesvos, from Togo
Asylum seekers are left to prepare for thecomplicated asylum procedure without support
of a lawyer and little access to information whilst
exposed to other post migration stressors suchas unsafe living conditions. Only a third of MSF
patients on Lesvos had access to legal assistanceduring their asylum interview. Without reliable
legal advice, it is impossible for many people toboth fully understand the procedure and havethe best chance at receiving protection. This isvery distressing for all asylum seekers, especiallythose with mental health conditions or survivorsof violence. They face the additional risks ofbecoming re-traumatised and being forcibly
returned to places where they may face further
violence or not have access to appropriate care.
The fast-track border procedure on the Greek
islands continues to violate safeguards thatare meant to provide additional protections
for vulnerable asylum seekers. Since its
implementation, MSF and PROASYL/RSA havenoted that vulnerable asylum applications havebeen systematically channelled into the borderprocedure without access to adequate support
or protections.36 In 2020, the Greek authorities
began implementing the International Protection
Act, which aims to speed up asylum procedures,
expand the grounds for detention and ultimately
increase the rate of returns. It has been widely
criticised as an attempt to lower protection
standards and create hurdles for people seeking
protection.37
On many occasions, the asylum service has
shown a complete disregard for applicants’
health. Recently, an MSF patient who had
been recognised as a survivor of torture by
the reception service officials was repeatedly
summoned to asylum interviews, where he was

CONSTRUCTING CRISIS AT EUROPE’S BORDERSre-traumatised again and again. This caused a
severe deterioration in his psychological state
and, as a result, he was hospitalised on four
separate occasions, including being urgently
transferred from the asylum service offices to thehospital’s emergency ward. On one occasion, theasylum service attempted to serve a notification
while the applicant was inside an ambulance.

The expansion of detention
The use of administrative detention as a precursor
to deportation has increased in Greece overthe last few years. The situation in pre-removal
centres is deplorable; in 2014, MSF denounced
conditions in Greek detention centres as posing
a threat to detainees’ health and safety.38 The
expansion of the use of detention upon arrival in
the hotspot model further places people at risk,
depriving them of their liberty and excluding
them.
Initially, only the hotspots in Lesvos and Kos
had pre-removal centres; however, in the new
MPRICs, all centres will have an expanded preremoval centre. In 2016, the Greek authorities
began a pilot project in Lesvos and Kos where
people from countries with an asylum acceptance
rate below 25 % were immediately detained on
arrival. These people remained in detention for
their entire asylum procedure. This amounts todiscrimination based on nationality.
According to a 2018 report by the European
Committee for the Prevention of Torture andInhuman or Degrading Treatment or Punishment,
conditions of detention for migrants were prisonlike, filthy, with poor sanitary conditions andventilation. The committee found that medical
screenings to identify those with health problems
or vulnerable people, such as unaccompanied
minors, were not systematically occurring39. MSF
frequently visited the pre-removal centre in theMoria RIC to follow up with patients who weredetained. Detainees often had limited access to
medical doctors and psychosocial assistance. For
example, in the Moria RIC there were no doctors
available in the pre-removal centre and timely
medical assistance was deprived to detainees,
even though some had high fevers or were having
a psychotic crisis.

“In 2019, we were informed that one of ourpatients, who was suffering from severe
mental health conditions because of theextreme violence they had suffered, wasdetained inside the pre-removal centre of theMoria RIC and required medical assistance[…]. Our psychologist, psychiatrist, cultural
mediator and I were allowed by the police
to enter the pre-removal centre and see ourpatient. When they brought him to us, hecould not recognise us, he could not tell us
where he was, where he was from, or whattime of the year it was. He was completely
broken.”Liza Papadimitriou, MSF case work
supervisor, Lesvos (2019).
For years, our teams on Lesvos have seen thatadministrative detention is more of a norm rather
than an exception. MSF has regularly intervenedin the pre-removal centre in the Moria RIC tofollow up and support patients suffering frommental and physical pain. Two such patients weredetained in the Lesvos pre-removal centre in2020 and it required the intervention of the Greek
Ombudsman and the European Court of Humanrights, among others, to revoke the detention anddeportation orders.
Despite this, the new MPRICs aim to further
expand the capacity of Greek authorities todetain people upon arrival and further reinforce
the most dangerous elements of the hotspot
approach.

An MSF health promotion team walks through Vathy
Hotspot, Samos, March 2020, © ENRI CANAJ / MAGNUM PHOTOS FOR
MSFThe EU plan to intensify its dangerous hotspot approach on Greek islands

21|Moving Forward: EU Intensifies its
Dangerous Approach

A view of the new Multi-Purpose Reception and Identification Centre, Samos, May 2021, © DORA VANGI/MSF“Europe is a country of freedom, but why are
you taking our freedom from us? You want
us to be in prison. Being in that new camp,
we will not be considered as refugees but assomeone who committed a crime. If I did acrime I go to prison, but I did not commit any
crime I am just a refugee”
Ali, 32 years old in Samos, from Syria|22

The renewed and intensified hotspot
approach: MPRIC red flags
Despite EU Commissioner Johansson’s promiseof ‘no more Morias’ after a fire burned down
the infamous Moria camp on Lesvos, the EU isreinforcing and institutionalising this approachwith its proposed Migration Pact and the MPRICs.
MSF is extremely concerned about the humancost of the new ‘closed camps’ and the impact
they will have on the health and well-being ofpeople contained in them.

CONSTRUCTING CRISIS AT EUROPE’S BORDERSMSF’s five key concerns about the MPRICs are
explained below. These are based on what ourteams have seen and heard, together with our
medical humanitarian experience working on theislands and supporting people who have suffered
as the result of the EU’s migration policies. Since
2016, MSF has consistently challenged the policyof containment on the Greek islands. Today, we
are witnessing the EU’s increasing attempts
to normalise structural violence, racism andpolicies that focus on security, border control
and deterrence rather than on protecting
people’s health and respecting their fundamental
rights. The MPRICs use the Moria camp as their
blueprint; they renew the hotspot approach andintensify the destructive EU containment policies
that are unnecessary, inadequate, damaging topeoples’ health and an abuse of human rights.
1. Structural violence causing mental healthand protection crisis“In this new camp they will have big problems
because they will put everyone together ina closed camp. […] I hope no one will go tothat camp because, if people go there, a lot of
people will lose themselves. In the new closed
camp, there will be a lot of violence and theft;a lot of protest. It will be an endless problem,
every day.”Ali, 32 years old in Samos, from Syria

being. If we are looking at the big picture, thewhole system needs to be changed.”
Katrin Brubakk, MSF child psychologist in
LesvosContainment in the MPRICs will inflict immediateand long-term harm. It will deny people theirfundamental rights to dignity and respect forphysical and mental health.41 Most patientstreated by MSF on the Greek islands were alreadytraumatised when they arrived. Given the mental
health needs we have witnessed over the past
five years, we anticipate a worsening crisis whenpeople are put inside the MPRICs.
The implications are not only psychological. MSF
has serious concerns about the lack of safety andthe potential for physical harm in the MPRICs,
particularly for women, children and people who
identify as LGBTQI+. According to the European
Commission, the MPRICs will have ‘safe zones’ forunaccompanied minors and vulnerable people.42
However, based on what MSF has witnessed in the
hotspots so far, it is hard to believe that any zone
inside the MPRIC can be reasonably designatedas ‘safe’.
2. A rushed, and harmful process puts the rightto asylum in jeopardy
The Memorandum of Understanding between theEuropean Commission and Greek government
regarding the MPRIC on Lesvos states that people
arriving on the island will undergo ‘screening
upon arrival with health checks and security
checks and will be adequately informed of theseprocedures’.43 However, five years’ worth ofexperiences have shown these procedures to be
opaque, arbitrarily implemented and harmful.

Described as ‘state of the art’40 by the European
Commission, the MPRICs will hold people inshipping containers, surrounded by barbed wire
fences. There is no possible way these facilities
can be sold as an improvement in people’s living
conditions. Despite having a larger planned
capacity than the RICs, the MPRICs cannot
hold the current number of asylum seekers on
the islands. This means that overcrowding will The new screening process proposals, which
continue to contribute to poor living conditions, will determine whether a person can begin theirand health and protection concerns for people asylum procedure and or be immediately marked
inside. Structural violence on such a scale will for return, will take no more than five days. This
only worsen the current public health and fast-track procedure will have fewer protections
and will likely mean more vulnerable people
protection emergency.
will be overlooked. According to the proposed
Migration Pact, following their screening, an“It’s a system to contain them and to breakasylum seeker’s case will be examined through a 12
them down. This is not the solution; notweek border procedure if they are from a country
even if you make it a bit fancier by havingwith a low recognition rate for international
mattresses and blankets to sleep on or if you
protection.44 This erodes their right to asylum bymake the food line a bit shorter or give themfailing to recognise the fact that asylum seekers
two apples instead of one. That still is not
do not come from pre-defined countries, and all
dignity. That is no way to treat a humanpeople have a right to seek asylum, if they have awell-founded fear of persecution. For those who

The EU plan to intensify its dangerous hotspot approach on Greek islands

23|qualify for the normal asylum procedure, this will
also be ‘fast and efficient’, this can be a welcomed
step but the process must also be fair, dignified,transparent and with appropriate support, which
has not been the case to date.
The potential for refoulement is increased by
the proposed Pact’s emphasis on returns, withthe creation of a returns coordinator and theopportunity for EU countries to sponsor returns
in an act of so-called ‘solidarity’ between states.45
The Pact and the MPRICs will enable moredetentions and mass deportations. This is asignificant step backwards for people’s rightto seek asylum, which legitimises potential
increased breaches of human rights.
3. Increased security and segregation from therest of society and services“I saw some videos about the new camp. It
is like an army barracks; it is a closed camp.
They going to bring us into the new camp. I
don’t want to think about this new camp.”
Mubarak, 25 years old in Samos, from Syria
The new MPRIC in Zervou, on Samos island, hasbeen built in a remote hillside far from any towns
and completely isolated from public services.
There is a heavy focus on security with a double
fence perimeter, space for police patrols andfenced areas inside demarcating different zones.
The site’s digital security system will include
surveillance cameras and security gates secured
with a fingerprint system for controlled entrance
and exit. The MPRIC epitomises total control
and securitisation of migration management,
removing any agency from the individuals
contained in the system. As MSF has witnessedcountless times before, lack of agency and control
is a key factor in the deterioration of detainees’
mental health.

“The good thing about working outside of thecamp is that we can actually create a safe
space. It’s very different. It’s very clear that
this is a place that is safe, where nobody canharm you. That no police can knock on thedoor and say come out here. […] I mean if weare talking about a safe environment for achild, it doesn’t mean being imprisoned.”
Katrin Brubakk , MSF child psychologist in
LesvosSegregating people from the rest of the islandin such a securitised facility is degrading,dehumanising and paints them as criminals
when they are only exercising their right toseek asylum. Rather than segregation, the focus
should be on integration.
4. Increased detention depriving people of theirliberty“I heard that there is a new closed camp;
people cannot go out; it is like a prison. Hereit is open, we can go outside, and I alreadyfeel like I’m in a prison.”
Abdul-Aziz, 32 years old on Samos, fromAfghanistan
Detention is becoming the norm rather than ameasure of last resort. Geographic restrictions
containing asylum seekers to the Greek islands
during their asylum process will continue.
However, the MPRICs will further restrict
movement to within the facilities themselves.
New arrivals will be in de facto detention and will
be unable to leave the MPRIC at all for 25 days.
“Imagine if you are a victim of torture andyou have been jailed in your country oforigin. Then you come to Greece and you
are expecting freedom or support. Instead
you find yourself in a jail… If there is one
thing that is becoming apparent through the
COVID-19 pandemic, it is how difficult it is tolive under conditions where you do not havefreedom of movement.”
Greg, MSF psychologist in Lesvos

Despite current shortcomings in health services,
there will apparently be medical and otherservices inside the MPRICs. People will be
unlikely to have easy access to healthcare andother services, or to safe spaces outside thefacility. MSF has seen the children’s playground The new Samos MPRIC is designed to enablesurrounded by high barbed wire fencing inside the control of when and how more than 2,000 people
Samos MPRIC. In line with the view of MSF child awaiting their asylum decision can enter and exit
psychologists, the EU Agency for Fundamental the camp. This creates opportunities for arbitrary
Rights (FRA) has stated that, “Children should and discriminatory restrictions on freedom
never be exposed to a prison-like environment of movement. The arrival of COVID-19 to thewith barbed wire fencing and should not be Greek islands provided a preview of how easily
detained for immigration-related purposes.”46|24

CONSTRUCTING CRISIS AT EUROPE’S BORDERSA view of the new Multi-Purpose Reception and Identification Centre, Samos, May 2021, © DORA VANGI/MSF

discriminatory restrictions can be imposed on
asylum seekers and refugees.
All new MPRICs will have pre-removal detention
centres, just like the Moria and Kos RICs did. The
Samos MPRIC will apparently include a separate
pre-departure centre with space for 900 people
to be detained before deportation. This is new for
Samos. Combined with the new pre-entry borderscreening regulation, the pre-departure centres
could lead to the widespread detention of people
seeking international protection. The MPRICs
risk becoming mass containment camps at the
EU’s border, depriving people of their liberty.
5. Decreased humanitarian assistance and moreinvisible suffering“I am the one with the privilege to talk to you.
I am talking on behalf of the people that are
struggling there, that need a better life. They
need protection. They need humanitarian aid.
They need rescue.”
Abdulrahim, Lesvos

The closed camps will make people’s suffering
more invisible and further isolate the mostvulnerable. A more restrictive environment forhumanitarian assistance is already underway
in Greece, with criminalisation of response atland and sea47 and a new discriminatory NGO
registration law implicating those wishing to help
asylum seekers and refugees.48 This is amplified
by increasingly xenophobic discourse and thecriminalisation of those who seek asylum, suchas the case of a father who was charged when his
son drowned trying to reach Samos.49
The question of whether humanitarian actors
can adequately respond to the population’s
needs in a principled way is stronger than ever.
The detrimental consequences of shrinking
humanitarian space mean a lack of solidarity,
safe spaces, protection and good quality
services for people. Controlling the areas where
humanitarian organisations can operate prevents
them from witnessing potential abuses and solimits accountability; independent actors areunable to expose unacceptable situations andhold authorities accountable.

The EU plan to intensify its dangerous hotspot approach on Greek islands

25|Conclusion

MSF is outraged by the crisis we continue towitness on the Greek islands. We have written
numerous previous reports, press releases andbriefings calling for action and demanding acomplete change in the EU’s approach towards
migration. Yet these calls have fallen on deaf ears.
This report details the appalling implications of
the EU’s hotspot approach on the health, wellbeing and safety of people trapped on the islands,
who have sought help and support in MSF clinics
over the past five years. It is sickening that the EU
and Greek authorities are proceeding with plansfor new closed camps on the five island hotspots.

It is astonishing that the European Commission
intends to institutionalise the hotspot approachthrough the new EU Migration Pact. A completechange is desperately needed. It is not too latefor European leaders to act with compassion andcommon sense. People seeking safety in Europe
must be treated with dignity and their lives, healthand well-being must not be put at risk any longer.
MSF once again calls on European leaders andthe Greek government to take accountability,
recognise the harm caused, and to end theirdeadly and dangerous approach.

Art beneath a barbed wire fence of Vathy hotspot, Samos, September 2017, © TIZIANA CAULI/ MSF|26

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

The EU plan to intensify its dangerous hotspot approach on Greek islands

27|References

1 Ministry of Citizen Protection (6 May 2021), National Situation
Picture Regrading Eastern Aegean Sea, https://infocrisis.gov.
gr/13156/apotyposi-tis-ethnikis-eikonas-katastasis-gia-toprosfygiko-metanasteftiko-zitima-tin-6-5-2021/
2 Médecins Sans Frontières (2016), Greece: Vulnerable People
Left Behind, https://www.msf.org/greece-2016-vulnerablepeople-left-behind; Médecins Sans Frontières (2017),
Confronting a Mental Health Emergency on Lesvos and Samos,
https://www.msf.org/greece-eu-border-policies-fuelmental-health-crisis-asylum-seekers
3 Ministry of National Defence (November 20 2019), Five
step plan on immigration [Press Conference], https://www.
amna.gr/home/article/409666/Pente-sun-mia-draseis-tiskubernisis-gia-to-metanasteutiko
4 Médecins Sans Frontières (2018), Nauru : Indefinite Despair,https://www.msf.org/indefinite-despair-report-andexecutive-summary-nauru
5 Luyten, K., & Orav, A. (2020), Hotspots: at the EU
External Border: State of Play [Briefing], European
Parliamentary Research Service, https://www.europarl.
europa.eu/RegData/etudes/BRIE/2020/652090/EPRS_
BRI(2020)652090_EN.pdf
6 Ibid, p.3
7 European Commission (27 January 2021), Closing
presentation of Beate Gminder at LIBE Committee;
Exchange of views on the current situation in Greek Islands[PowerPoint presentation].
8 European Commission (2 December 2020), Memorandum ofUnderstanding between the European Commission, European
Asylum Support Office, the European Border and Coast Guard
Agency, Europol and the Fundamental Rights Agency, of theone part, and the Government of Hellenic Republic, of theother part, on a Joint Pilot for the establishment of a new
Multi-Purpose Reception and Identification Centre in Lesvos,
https://ec.europa.eu/home-affairs/sites/default/files/
pdf/03122020_memorandum_of_understanding_en.pdf, p.2
9 Ibid, p.5
10 Lawspot (2020), List of Safe Countries of Origin of Asylum
Seekers, https://www.lawspot.gr/nomika-nea/o-katalogosme-tis-asfaleis-hores-katagogis-ton-aitoynton-asylo-kya
11 International Protection Act (2019), Article 83, Law
4636/201912 Leiler, A., Hollifield, M., Wasteson, E., & Bjärtå, A.
(2019). Suicidal Ideation and Severity of Distress among
Refugees Residing in Asylum Accommodations in Sweden.
International journal of environmental research and publichealth, 16(15), 2751. https://doi.org/10.3390/ijerph16152751
13 Eagle, G. & Kaminer, D. (2013), Continuous traumaticstress: Expanding the lexicon of traumatic stress, Peace andConflict: Journal of Peace Psychology, 19(2), p.85

|28

14 International Protection Act (2019), Article 54, Law
4636/201915 HRW (June 2017), EU/Greece: Pressure to Minimize
Numbers of Migrants Identified As ‘Vulnerable’ https://www.
hrw.org/news/2017/06/01/eu/greece-pressure-minimizenumbers-migrants-identified-vulnerable
16 Schock, K., Rosner, R., & Knaevelsrud, C. (2015), Impactof asylum interviews on the mental health of traumatizedasylum seekers, European journal of psychotraumatology, 6,26286. https://doi.org/10.3402/ejpt.v6.26286
17 Médecins Sans Frontières (2018), Nauru : Indefinite Despair,https://www.msf.org/indefinite-despair-report-andexecutive-summary-nauru
18 Ministry of Health, Special Committee for the Protectionof the Rights of Persons with Mental Health Disorders(March 2021), Recommendations for the Mental Health Careof Asylum Applicants and Refugees, https://www.moh.gov.
gr/articles/citizen/dikaiwmata-lhptwn-yphresiwn-ygeias/
eidikh-epitroph-elegxoy-prostasias-twn-dikaiwmatwntwn-atomwn-me-psyxikes-diataraxes/5868-ektheseisporismata
19 Fallon, K. (19 March 2021), ‘We were left in the sea’: asylum
seekers forced off Lesbos, https://www.theguardian.com/
global-development/2021/mar/19/asylum-seekers-forcedoff-lesbos-pushback-crisis-europe-borders, The Guardian,(accessed: 23 April 2021)
20 Tondo, L. (5 May 2021), Revealed: 2,000 refugee deaths linked
to illegal EU pushbacks, https://www.theguardian.com/
global-development/2021/may/05/revealed-2000-refugeedeaths-linked-to-eu-pushbacks, The Guardian (accessed 6
May 2021)
21 Médecins Sans Frontières (2020), Summary of MSF MedicalHumanitarian Intervention on Border Violence in the Balkans:
2016-2020 [Briefing Note], Brussels.
22 European Commission (3 March 2020), Remarks by President
von der Leyen at the joint press conference with Kyriakos
Mitsotakis, Prime Minister of Greece, Andrej Plenković,
Prime Minister of Croatia, President Sassoli and President
Michel [Statement], https://ec.europa.eu/commission/presscorner/detail/en/statement_20_380
23 European Parliament (6 July 2020), Investigate alleged
pushbacks of asylum-seekers at the Greek-Turkish border
MEPs demand, https://www.europarl.europa.eu/news/en/press-room/20200703IPR82627/investigate-pushbacksof-asylum-seekers-at-the-greek-turkish-border-mepsdemand
24 Ibid
25 Barigazzi, J. (11 January 2021), EU watchdog opens
investigation into border agency Frontex, https://www.
politico.eu/article/olaf-opens-investigation-on-frontex-forallegations-of-pushbacks-and-misconduct/, Politico

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

26 GLAN (March 2021), Drift-backs and torture on the Aegean,
https://www.glanlaw.org/aegean-push-backs
27 Fallon, K. (19 March 2021), ‘We were left in the sea’: asylum
seekers forced off Lesbos, https://www.theguardian.com/
global-development/2021/mar/19/asylum-seekers-forcedoff-lesbos-pushback-crisis-europe-borders, The Guardian
28 See annex
29 Ministry of Citizen Protection (2020), National Situation
Picture Regrading Eastern Aegean Sea, https://infocrisis.gov.
gr/13156/apotyposi-tis-ethnikis-eikonas-katastasis-gia-toprosfygiko-metanasteftiko-zitima-tin-6-5-2021/
30 HRW (April 2021), Greece: Lead Contamination
Threat to Migrants Unresolved, https://www.hrw.org/
news/2021/04/01/greece-lead-contamination-threatmigrants-unresolved
31 FRA (2019), Update on the 2016 Opinion of the European Union
Agency for Fundamental Rights on the fundamental rights inthe ‘hotspots’ set up in Greece and Italy, https://fra.europa.eu/
sites/default/files/fra_uploads/fra-2019-opinion-hotspotsupdate-03-2019_en.pdf, p.8
32 ECRE (November 2020), Greece: Well-run PIKPA Camp
Evicted while Situation on Islands and Mainland Continue to
Deteriorate, https://www.ecre.org/greece-well-run-pikpacamp-evicted-while-situation-on-islands-and-mainlandcontinue-to-deteriorate/

44 European Commission (23 September 2020), New Pacton Migration and Asylum: Questions and Answers, https://
ec.europa.eu/commission/presscorner/detail/en/
qanda_20_1707#who-apply
45 Ibid
46 Fundamental Rights Agency (26 March 2021), Initial
Reception Facilities at External Borders; 12 points for guidance,
https://fra.europa.eu/en/publication/2021/initial-receptionfacilities-external-borders#TabPubTwelvepointsforguidan
ce1
47 Keep Talking Greece (28 September 2020) Greece files
against 33 NGO members for assisting human traffickers
https://www.keeptalkinggreece.com/2020/09/28/greecengo-members-human-traffickers-lesvos-turkey/ [accessed
21 May 2021]
48 Council of Europe (November 2020), Expert Council on NGO
Law calls Greece to revoke restrictions on the registration andcertification of NGOs, https://www.coe.int/en/web/specialrepresentative-secretary-general-migration-refugees/
newsletter-november-2020/
49 Fallon K., (16 November 2020) Father faces criminal chargeover sons death in migrant boat tragedy, https://www.
theguardian.com/global-development/2020/nov/16/fatherfaces-criminal-charge-over-sons-death-in-migrant-boattragedy#img-1 The Guardian [accessed 21 May 2021]

33 AIDA (June 2020), Country Report: Greece, https://asylumineurope.org/wp-content/uploads/2020/07/reportdownload_aida_gr_2019update.pdf
34 ibid
35 Ibid
36 MSF, PROASYL & RSA (2021), Border procedures on
the Greek islands violate asylum seekers’ right to special
procedural guarantees, https://rsaegean.org/en/rsa_msf_
proasyl_specialproceduralguarantees
37 Greek Council for Refugees (2020), GCR’s comments on
the draft law amending asylum legislation, www.gcr.gr/en/
news/press-releases-announcements/item/1434-gcr-scomments-on-the-draft-law-amending-asylum-legislation
38 Médecins Sans Frontières (2014), Greece: Invisible Suffering
Report, https://www.msf.org/invisible-suffering
39 European Committee for the Prevention of Torture andInhuman or Degrading Treatment or Punishment (2019),
Report to the Greek Government on the visit to Greece, https://rm.coe.int/1680930c9a
40 European Commission, (27 January 2021), Exchange of viewson the current situation in Greek islands and Memorandumof Understanding in LIBE Committee [presentation], https://
multimedia.europarl.europa.eu/en/exchange-of-views-onthe-current-situation-in-greek-islands-and-memorandumof-understanding-in-libe-committee_I201634-V_v
41 Official Journal of the European Union (2012), Charter ofFundamental Rights of the European Union, https://eur-lex.
europa.eu/legal-content/EN/TXT/?uri=CELEX:12012P/TXT
42 European Commission (2 December 2020), Memorandum ofUnderstanding between the European Commission, European
Asylum Support Office, the European Border and Coast Guard
Agency, Europol and the Fundamental Rights Agency, of theone part, and the Government of Hellenic Republic, of theother part, on a Joint Pilot for the establishment of a new
Multi-Purpose Reception and Identification Centre in Lesvos,
https://ec.europa.eu/home-affairs/sites/default/files/
pdf/03122020_memorandum_of_understanding_en.pdf
43 Ibid

Contributors
Andrea Contenta, Emily May, Reem Mussa,
Elisavet Papadimitriou
Special thanks to all the field, operations andcommunications staff who provided and and reviewed
material for this report.

The EU plan to intensify its dangerous hotspot approach on Greek islands

29|Annex:Reported Deaths in Hotspots

Date

Location

Description

Source23-06-16

Chios

Egyptian man was fatally wounded
during fight and died in hospital

https://rsaegean.org/en/
greek-hotspots-deaths-not-to-be-forgotten/

24-11-16

Lesvos66-year-old woman and 6-year-old
child died after a portable cooking
gas stove exploded inside a tent,setting on fire parts of the Moria
RIC. A 30-year-old woman and afour-year-old child were seriously
injured.

https://www.euronews.com/2016/11/25/
greece-explosion-and-fire-reported-atmoria-refugee-camp-on-lesbos-at-least-2

24-01-17
28-01-1730-01-17

LesvosThree refugees — an Egyptian, aSyrian and a Pakistani — died at
the Moria RIC. Reports suggest thatthe refugees had inhaled the fumes
from makeshift stoves in theirtents.

https://www.europarl.europa.eu/doceo/
document/E-8-2017-004100_EN.html

24-01-17Samos

42-year-old Kurdish man died in
the hospital

http://moving-europe.org/
death-in-greek-camps/

31-03-17Chios

29-year-old Syrian man set himself
on fire at the Vial hotspot.

https://rsaegean.org/en/
greek-hotspots-deaths-not-to-be-forgotten/

24-08-19

Lesvos15-year-old unaccompanied minor
stabbed in Moria RIC safezone,

https://rm.coe.int/cc173casedoc7en-response-to-the-gvt-ssubmissions/1680995335

24-09-19

Lesvos5 years old child killed by a truck
while playing

https://www.in.gr/2019/09/24/greece/
thanatos-sti-moria-o-5xronos-thyma-toudiarkous-egklimatos-kai-tis-ypokrisias-stoprosfygiko/

30-09-19

LesvosWoman and child die in fire incontainer followed by riots

https://www.kathimerini.gr/
society/1044951/dyo-nekroi-apo-tinpyrkagia-sti-moria-leei-o-perifereiarchisvoreioy-aigaioy-vinteo-fotografies/

17-11-19

Lesvos9-month baby dies fromdehydration in Moria RIC

https://www.euronews.com/2019/11/17/
baby-dies-in-moria-migrant-camp-msfreveals|30

CONSTRUCTING CRISIS AT EUROPE’S BORDERS

15-01-20

LesvosCongolese asylum seeker stabbedin Moria RIC

https://www.infomigrants.net/en/
post/22268/life-in-the-moria-camp-onlesbos-every-day-someone-is-injured

01-06-20

Lesvos

31 years old Iranian man was foundhanged in the pre-removal centreof Moria

https://legalcentrelesvos.org/2020/02/07/
press-release-a-criminal-complaintfiled-regarding-the-death-of-a-31-yearold-iranian-national-at-the-pre-removaldetention-centre-of-moria/

16-01-20

Lesvos

20 years old Yemeni man stabbed in
Moria RIC

https://www.infomigrants.net/en/
post/22268/life-in-the-moria-camp-onlesbos-every-day-someone-is-injured

16-03-20

Lesvos

6 years old child dies in firehttps://www.cnn.gr/ellada/story/211435/
nekro-exaxrono-paidi-sti-moria-meta-apofotia

24-06-20Samos

31-year-old man from Ghana diedin the camp

https://www.efsyn.gr/ellada/
dikaiomata/249424_o-samioyel-pethanekathos-den-eihe-parapemptiko-staepeigonta

24-03-21Kos

44 years old man from Guinea
Conakry dies from peritonitis inside
the pre-removal of Kos RIC

https://dm-aegean.bordermonitoring.
eu/2021/03/26/another-death-in-prisonoutrage-in-kos-detention-centre-aftermedical-attention-withheld/

03-05-21Chios

28 years old Somali man founddead in his tent surrounded by rats

https://www.theguardian.com/globaldevelopment/2021/may/07/a-scene-outof-the-middle-ages-dead-refugee-foundsurrounded-by-rats-at-greek-camp

09-05-21Chios

51 year old Iraqi man found dead,due to ongoing health issues

https://greekreporter.com/2021/05/10/
second-asylum-seeker-found-dead-greecechios-camp/

The EU plan to intensify its dangerous hotspot approach on Greek islands

31|

MSF in Greece
Médecins Sans Frontières/Doctors Without Borders (MSF) has been providing medical and humanitarianassistance to asylum seekers, refugees and migrants in Greece since 1996.
Since 2016, MSF has remained on the Greek islands toprovide medical and mental healthcare to migrants on
Lesvos, Samos, and Chios (closed 2019). Our activities
include providing mental health care to children
and adults, vaccinating children against commonchildhood diseases, providing sexual and reproductive
healthcare, treating chronic diseases, and providing
water and sanitation services. MSF runs two clinics
in Athens, a day center providing medical and mental
healthcare and a specialized clinic for survivors of
torture and ill-treatment.

LAYOUT: RUDI DE RECHTER & LIZ MORRISON / 06/2021

In 2015, MSF expanded its activities in Greece tomeet the humanitarian needs of people on themove arriving in Greece. MSF set up emergency
interventions on Lesvos, Samos, and Chios, as wellas the Dodecanese Islands, Athens, and Idomeni
providing medical and mental health care, shelter,
water, and sanitation services and distribute relief
items to refugees and migrants. Between December
2015 to March 2016, MSF conducted life-saving searchand rescue operations in the Aegean Sea, off the coastof Lesvos, and provided medical assistance at landing
points. In March 2016, MSF decided to suspend all
its activities inside the Moria ‘hotspot’ after the
EU-Turkey Deal.

Médecins Sans Frontières | Γιατροί Χωρίς Σύνορα
https://www.facebook.com/medecinssansfrontieres@msf_sea
www.msf.org/greece