‘What’s on her mind?’ I was attempting to understand what had caused this young woman to have such a severe panic attack, when she had been making slow but significant progress over the previous few weeks. I had seen her on an almost daily basis, usually with one of her four children. She was nursing a toddler with a chesty cough that kept him awake all hours of the night, and her older sons were forever getting themselves into trouble. They were struggling to find a suitable outlet for their boisterous energy and confused teenage emotions in the confined space of the refugee camp. She had steadfastly held her family together despite battling her own depression. Today she had come alone, trembling and hyperventilating, until we found her a chair in a quiet corner where she could slow her breathing and talk. My translator’s usually calm expression transformed into one of horror as she managed to utter a few words. He spoke to her gently. ‘Sabar, sabar’ Patience, patience. ‘Inshallah’ Trust in god’s will.
I felt drawn to work in a refugee clinic for a mixture of reasons. Reading reports about the situation in Syria and the terrible risks people are taking in order to escape, I wanted to see for myself what the response has really been like and what conditions people are living in whilst they wait for their asylum cases to be processed. Other volunteers talked about this too – the desire to ‘see for ourselves’ and on the surface it seems absurd and voyeuristic. But I think it comes from a disbelief that our own countries are not doing more to help, and somehow hoping that we can redress the balance. I knew it was going to be near impossible to make any kind of significant contribution as a short term volunteer, and had mixed feelings about the role of charities and non-governmental organisations, especially now it is clear that the crisis is set to continue. However, I do believe it is worthwhile to show our support. Much of what I do at home as a GP is about listening and acknowledging people’s pain – whether it is physical or emotional. I’ve come to appreciate how powerful that can be in helping people find their way through life’s difficulties. So when contemplating what I might be able to offer as a volunteer, if nothing else, I hoped I could be a listening ear and fellow human being.
After almost a year of emailing various groups and following the ever-changing situation in Greece, we arrived in the country expecting to work for the Syrian American Medical Society. At the last moment we discovered that most of their allocated camps had been dispersed, but they put us in touch with another NGO who were in need of staff; Team Kitrinos. Apart from a website that had rapidly become out of date, we knew nothing about this fairly new, British organisation other than it was the allocated primary care provider in a couple of camps near Thessaloniki, and were also operating a mobile clinic for refugees who had been sent to hotels during the cold weather. I would be working as a GP, but Max’s role was less clear – we hoped that he would be able to provide admin support to the clinics, or find a practical role with one of the other NGOs operating there.
On our first night in the volunteer house I bombarded the others with a million questions. It seemed pretty disorganised, but I later realised how fast the situation changes and how difficult it is to plan for. There were no long term clinical staff on the ground to give an induction to the camps or explain the clinic operations. Of the volunteer doctors, only one had been there for more than a week. Our systems and equipment were set up for other camps that had spontaneously been moved, with no warning from the Greek authorities. Where the team was now working, healthcare provision was in the process of handover from the previous provider which had established a first aid-type service, staffed mainly by paramedics. Their manager had planned to stay on to help with our orientation, but had unfortunately had to leave under unexpected circumstances. We did have contact with our medical director via Skype who guided us through the first few weeks until a new manager was flown in. And we had a secret weapon; our Greek coordinator who had an ear to the ground in the ministry for migration, understood the internal camp politics and, crucially, spoke both Greek and excellent English.
The camp where I spent most of my time, ‘Elpida’ was in a disused warehouse on the northeast side of the city, next to a huge cement works. The building itself was in disrepair with crumbling walls and exposed pipes and electrical cables, despite attempts to make it safe. It was on two floors; the first floor had been converted by putting in partition walls to create about forty separate rooms. During our time there it housed about 165 people. The ground floor was a huge open storage area but there were plans to convert this too, if the Greek authorities gave the go ahead. Most of my understanding about the practical running of the camp I learnt through Max. He was very quickly recruited by ERCI (Emergency Response Centre International), the organisation who were carrying out day to day operations, and delivering school education. He was appointed to their ‘infrastructure’ team, which involved tasks as varied as building (and rebuilding) furniture, fixing plumbing and electrical problems and making things from improvised materials, from talent show props to gym apparatus!… He was also a mine of useful information and contacts for our medical team.
Although conditions were less than ideal, there was a real creative energy about the place. Volunteers had put thought, time and care into helping the residents make it look nicer; decorating communal areas with knitted blankets and hanging arts and crafts that the kids had created. A new, brightly coloured wall painting appeared every week, accompanied by uplifting messages in English or Arabic.
Unlike in most other camps, there were basic cooking facilities and residents received ingredients to make their own meals, an obvious but fundamental way of giving people back some autonomy. Items like clothes, toiletries and children’s toys could be bought from the on-site ‘shop’ using points which were allocated monthly, and based on the number of adults and children in a family. This idea came from the principles of the universal basic income, and its aim in this setting was to ensure that the distribution of donated goods was done in the most fair and dignified way possible. It also meant that households had to manage their own budget, in an attempt to create a bit of ‘normality’ out of a surreal situation. There were established mens and womens groups and a representative council, in order to encourage residents to engage with decision making and practical aspects of running the camp. All this must feel like a stark contrast to harsh conditions of the infamous camps like Idomeni (now closed) or in the reception centres on the islands where huge numbers of refugees continue to arrive by boat. Another important difference was that our camps were full of families with young children, and men and women of all ages (except for very few elderly). This helped create a more natural atmosphere, whereas in places where conditions are poor, the women and children tend to be moved on quickly, leaving a community of mainly young men. We heard that this has resulted in escalating tensions, not unsurprisingly when almost all of those men are suffering anxiety, depression or post-traumatic stress.
So, Elpida had a reputation for being one of the better camps, and because of this refugees were allocated to it on the basis of need; it receives those on the top of the UNHCR’s ‘most vulnerable’ list. This meant that despite our small patient population, the clinic had a surprisingly complex caseload. It included several children and teenagers with longterm conditions (HOCM, congenital adrenal hyperplasia, learning disabilities, progressive myoclonic epilepsy) as well as a handful of adults with more common chronic conditions like hypertension, diabetes and heart disease (or all three). We saw a slow but steady stream of people seeking medical care, often for viral illness or minor injuries, and alongside this we did a lot of chronic disease management. Living in close quarters meant that people were more at risk of infestations – we were constantly handing out nit or scabies treatments which was a source of great embarrassment amongst the residents. It was exceptionally difficult for them to be discrete in an environment where everyone washed and did their laundry communally. Women’s health was a huge unmet need as it was often the first time these women had stayed in one place for long enough to seek advice. It took some determined explanation from me at the women’s group, and word of mouth to work its way through the community, but eventually we won their trust and they started to understand that we could offer contraception and sexual health services even though we weren’t ‘specialists’. But above all else, we saw a very high frequency of symptoms such as poor sleep, headaches, exhaustion… all the classic physical problems of stress, or more serious underlying mental illness. We had limited resources, but one thing we had a plenty of was time, a long lost luxury in UK general practice. And more often than not, the best ‘drug’ we had to offer was to listen compassionately. The stories people told still shocked me. The woman suffering from panic attacks had told my translator that she had just heard from family in Syria that her brother was missing, and they feared he had been captured by ISIS. It’s not hard to imagine the terrifying scenarios she was playing over and over in her mind. We wrote many letters attempting to highlight people’s medical and psychological needs in the hope that this may add weight to their case for asylum. I still don’t know if any of these made a difference.
I was struck by how resilient people can be in the face of enormous adversity. It was surprising to me that people continued to function, to laugh and gossip, to play with their kids, cook and do their laundry. Not only this, but also to extend offers of food and drink to us on a constant basis! The Syrian culture of hospitality is such that, even though what they had was rationed they insisted on sharing it with us..and if we refused they would be genuinely disappointed. So we often found ourselves enjoying delicious home cooked dishes when we were supposed to be working in the clinic!!
In Team Kitrinos I felt incredibly fortunate to be part of a fantastic group of people, with a good balance of enthusiasm and realism. We had no power to change the reasons people were stuck in a refugee camp, but there was plenty of day to day clinical and admin work required that was within our control. And despite the variety of nationalities and healthcare backgrounds amongst us I was amazed to find that we had a common belief in primary care in the most holistic sense. We had arrived at a time when, coincidentally, most of our team were planning to stay for a bit longer than the average volunteer period, which meant we could really get to know each other, understand what was needed in the camps and work out how best to use our skills. Everyone seemed to be comfortable with the challenging circumstances and was quietly taking initiative to make little improvements to the clinic, consulting each other when needed or just getting on with the job. Over our six weeks it felt like a gradual evolution from chaos into some sort of order. The team managed to establish a simple electronic records system where notekeeping had previously been haphazard. All the children were weighed and measured to help with ongoing monitoring of their wellbeing and nutrition (this was especially important in one camp where pre-packaged food was being distributed, as without the ability for families to prepare their own food many of the children had lost their appetites.) We reorganised the emergency equipment and wrote some basic emergency guidelines which went some way to alleviating my anxiety about the reported long response times of the Greek ambulance service. We cobbled together a process for restocking the pharmacy, (which was a challenge as we were having to rely on several different organisations collecting donated drugs, many of which were entirely unsuitable, or researching ourselves what was available and affordable to buy locally) and we somehow found a way of ensuring the supply of our patients chronic medications.
We wrote a guide to help orientate new volunteers. We drafted guidelines for managing hypertension and diabetes in our particular context, which fell somewhere between the conflict zones that MSF guidelines are designed for, and the UK gold standards. We compiled a list of english-to-arabic phrases specifically for women’s health issues, which came in very useful when there were no female translators available. We even had fun decorating one of our clinics with the yellow and green Team Kitrinos colours! (‘Kitrinos’ means ‘yellow’ in Greek and the name originates from the colour of the bright yellow Swedish ambulance that was first used as a mobile clinic in Lesvos)
Working at the interface between an NGO and the Greek state healthcare system also highlighted for me how difficult things are for Greece, following the economic crisis. We were given a rota for emergency departments, so that we could work out which was open on what day – each city has introduced a system of rolling closures to save money, which means that there is only one department serving the whole of Thessaloniki and surrounding area. This explains why ambulances can take up to an hour, and why, one night on call, we decided to make the half hour drive to our furthest camp to a baby with breathing difficulties, in case we could start treatment before the paramedics arrived. We beat them by ten minutes. Mercifully the child was not in extremis.
Most investigations such as blood tests or X-rays were not available to us as non-Greek doctors, despite working within a Greek registered organisation and coming from within the EU. This meant either managing without, or referring into the Greek hospital system as primary care does not really seem to exist. (I was told that there are some GPs, ‘but people only go to them if they don’t know what’s wrong’!) There were very long delays for specialist referrals, even by current NHS standards. The last thing we wanted was to burden the system with unnecessary work, but at times we had no other option. Our best chance of getting an urgent appointment was at the Medicins du Monde polyclinic, which boasted doctors in most specialties. However we received confusing letters back from their service until we realised that, like us, their doctors had no authority to write prescriptions or order tests either! Meanwhile our patients became understandably more confused and frustrated. We started resorting to using social clinics or pharmacies, which seem to be increasing in number in Thessaloniki in response to burgeoning need.
Unsurprisingly, there were also long delays in the overwhelmed Greek asylum system. What was difficult to comprehend, however, was that many of the Elpida residents had actually already been granted their right to family reunification under the Dublin III regulation, but were still being held up in Greece, sometimes for months. We were told this was due to the ministry’s failure to release funds for transport to their destination country. Besides being one last agonising hurdle, this also made no sense as it must have been resulting in a significant cost to the government!
Street art depicting Greek anti-austerity riots in 2015
By far the most affecting aspect of the experience for me was working and living with our two translators who were themselves Syrian refugees. Our social time in the shared volunteer house was great fun with lots of joking and laughter. We enjoyed discovering culinary delights from all our respective parts of the world, and sharing snippets of each other’s home lives. But we also learnt about our Syrian friends’ personal journeys and the stories that had forced them to leave their country and their families. And although most of the time it was hidden, we occasionally glimpsed their struggle with loss and ongoing anxiety about loved ones. Kurdish New Year, ‘Nowrooz’ and Mother’s day were particularly difficult times for them, and we tried as best we could to offer our support, but often it felt impossible to provide any comfort. Their commitment to helping their fellow refugees was especially humbling given that they had their own crosses to bear and they often went above and beyond their duty, accompanying worried families during hospital admissions or making themselves available around the clock. At times I worried that they gave too much of themselves, close to the point of burnout (with which I am all too familiar from dedicated colleagues in the NHS.) All the time, in the background was the gnawing anticipation of the outcome of their own asylum applications, and a very uncertain future. Inevitably, there were times when the rest of us chatted about our own future plans, sometimes flippantly, musing over which country we’d like to visit next for example, and it would suddenly strike us how privileged we are, and how insensitive our comments sounded. We also enjoyed teasing them for their music tastes, especially their fondness for Celine Dion’s ‘My heart will go on’ from the blockbuster Titanic. It only dawned on me afterwards that many of our refugee friends would be able to genuinely relate to the film’s story. In addition to some great friendships forged from living and working together in a difficult environment, I also gained a more emotional connection with the tragedy of the war. It’s as if Syria now feels closer geographically and socially, and what’s happening there is much more real.
In an ideal world, I believe the refugee response should be met by the international community supporting national governments. In reality of course, this is not happening and in Greece it is difficult to see the situation improving anytime soon. Non-governmental, not for profit organisations like Team Kitrinos or ERCI are therefore providing a very necessary service. As far as we could see, they spend very little on advertising, have minimal overheads, and careful consideration goes into how money is spent after consultation with those on the ground and where possible, with refugees themselves. After our experience with these organisations we would certainly encourage others to volunteer or support their work. You can visit their websites to find out more…