Over the last decade, millions of refugees have arrived in Europe, often by crossing the Mediterranean by boat or by traveling by land via Turkey, through Greece and the Balkans to Western Europe (1). The number of people arriving rose slowly between 2010 and 2013 and then tripled in the two years that followed. In 2015, a record 1.3 million asylum applications were received in the EU (2), a situation that became known as the ‘migrant crisis’. In efforts to reduce immigration through the EU border-states, EU member states implemented various measures, notably the closure of the Balkan routes and the implementation of the EU-Turkey agreement in March 2016(3).
While immigration via Greece substantially decreased following the EU-Turkey agreement, the length of stay for a refugee at the Greek entry locations drastically increased due to a prolonged administrative process (1). Upon arrival, refugees generally reside in camps, which, even though originally designed as short-stay provision, became long-stay facilities. Some of these camps have detention-like characteristics and dire living conditions (4).
In accordance with the EU-Turkey deal containment policy, refugees are confined to the island on which they arrive until their asylum claims are adjudicated. Those who are deemed vulnerable (e.g. the elderly, sick, pregnant or those displaying severe mental health conditions) should be exempt from this policy and should be allowed to await the outcome of their asylum procedure on mainland Greece, where facilities are better (5). However, the lack of accommodation on the mainland and delays in the vulnerability assessment procedure leave thousands of eligible individuals and families trapped on the island (5).
The island of Lesbos (or Lesvos) was, and still is a key entry point in Greece for refugees (6). Hence, Lesbos houses several refugee camps, one of them being Moria camp, which has been repeatedly reported for being overcrowded, unhygienic, and unsafe (7) (8) (9) despite EU funding and the efforts of privately-funded non-governmental organizations (10) (11). Charlie Yaxley, a spokesman for the UN High Commissioner for Refugees (UNHCR), reported the following about the camp in August 2018: “We are particularly concerned about woefully inadequate sanitary facilities, fighting amongst frustrated communities, rising levels of sexual harassment and assaults, and the increasing need for medical and psychosocial care” (12).
In Moria camp, few refugees feel safe and well-treated (13). Psychological problems are omnipresent, and rates of attempted suicide are high (14). Health care access is poor, especially for mental health care, and services are mostly provided by a changing group of medical volunteers (15) (16). Multiple aid organizations have raised concerns about what they describe as a mental health crisis (7) (17). They have pressed the EU member states and the Greek government to improve living conditions and decongest the island, arguing that the camp conditions negatively affect the mental health of its inhabitants (18).
The claim that the camp conditions like those in Moria adversely affect mental health has some empirical support. It has been well established that, compared to the general population, the prevalence of mental health conditions (in particular PTSD, anxiety, and depression) is higher in refugees and other conflict-affected populations (19) due to pre-migration stressors (20). However, a growing number of studies in recipient countries found that imposed conditions of adversity, including prolonged detention or living in institutional accommodation, uncertain residency status, challenging refugee determination procedures, restricted access to services, and a lack of opportunities to work or study, combined in a way that compounded the effects of past traumas in exacerbating symptoms of PTSD and depression in this population (21) (22). In a series of studies, Miller et al. stressed the mediating role of daily stressors such as unsafe living conditions, challenges in meeting basic survival needs (access to water, food, shelter, healthcare), the inability to produce income, and isolation from family and traditional social supports, on the effect of past war-related trauma on mental health in refugees (23) (24) (25). In a study in two Rohingya refugee camps, it was found that, while PTSD symptoms were associated with both prior trauma exposure and environmental stressors (problems with food, lack of freedom of movement, and concerns regarding safety), depression symptoms were associated with daily stressors only (26). Studies that focus on the relation between the length of time spent in the asylum procedure (be it in immigration detention, a refugee camp, or another institutional accommodation) and mental health find a cumulative adverse effect (27) (28) (29). In turn, release from detention or being granted a permanent visa improves mental health (30) (31).
Two qualitative studies examining the link between Moria camp conditions and mental wellbeing both suggest that camp conditions (lack of safety and proper living conditions, institutional abuse, slow and constantly changing asylum procedure, lack of (mental) health service provision, lack of functional and supportive networks) lead to a deterioration in mental health (32) (33). This effect, however, has never been quantified.
This study aims to establish the relationship between the length of stay in Moria camp and mental health by using quantitative data provided by Moria Medical Support (MMS), a Dutch-registered medical NGO. MMS provided emergency medical care in Moria between nine o’clock in the evening and eight o’clock in the morning, seven days a week. As expected, working conditions were challenging because of limited resources and a lack of safety. See Box 1. We hypothesized that given the prevailing stressors (lack of safety, challenges in access to water, food, shelter, and healthcare, inability to produce income, lack of supportive networks, institutional abuse, and uncertainty regarding the length of the asylum procedure), a longer length of stay in the camp would negatively impact mental health.
Restricted by the nature of clinical activities at the MMS clinic and the healthcare situation in the camp, we focused on the relationship between length of stay and the incidence of acute mental health crises rather than mental health conditions in general. This will further be clarified in the methods section.
-----------------------
Text Box 1
The clinic consisted of a container with three small consultation rooms. Unable to gain medical access during the day, patients of all ages and nationalities would line up well before opening hours. A triage system was used to ensure that the worst cases were addressed, adding to desperation and anxiety in those turned away. Inside the clinic, there was often agitation and noise; earplugs were sometimes handed to patients to prevent panic or dissociation from being triggered. MMS staff had to lock themselves in and call the police on a regular basis, mostly because of threatening or aggressive patients. On one occasion, twenty armed men attacked the clinic, trying to assault a patient who was inside. The night watch of the police was outnumbered and could not prevent the clinic from being demolished and
patients and staff inside being assaulted. It marked the end of the clinic’s activities.
-------------------------------
No ethical approval was required for this study, as it only made use of data from secondary sources, routinely collected, anonymized information on patients.