Isme Aaminah Ana Tabeebah

I tried to write this post a couple of times whilst I was still out in Slovenia but I just couldn’t find the time or energy to do it justice. Now I’m home I’m trying to consolidate all the little notes I made to myself and I’m afraid this is going to be a mammoth post about everything I was thinking, feeling and witnessing whilst working the past week in Dobova. Its not the most flowing piece of writing and I hope you can manage to get to the end!

In total we worked the initial shift I already blogged about and then two 24hr shifts with 24 hour rest in between then another 9 hour shift on Christmas day. We saw 319 patients over those shifts with around 100 a day on the 24 hours shifts and a few less on the 9 hour shifts.  Generally, the shifts were much busier in the evenings and our first 24 shift started in a very chaotic way. A train had just arrived at 9pm when our shift began and over 1000 people were coming into the camp. We saw 40 patients in first 2 hours with another 55 in the next 6 hours including 4 very sick patients. On our second 24-hour shift finishing at 9pm on the 24^th we ended up staying another hour as the team we were handing over to consisted of just one doctor and when she arrived we had 2 very sick patients plus reports of a third needing to be picked up at the train station.

We noticed quickly that “batches” were much sicker than others and it was linked to which route they had taken and how long they’d be travelling without stopping. Those who had walked across Bulgaria rather than risk the sea were much more exhausted and seemed to have been more neglected health wise. Sometimes the make up of a train was mainly young healthy men and our only consultations for hours would be coughs, colds and headache. Then the next train would arrive and there would be large extended families with many pregnant women, new born babies, young children and old sick grandparents. I was so amazed at the resolve of families to bring along and continue to care for every member of their families including the wheelchair bound grandma with type 2 diabetes, the severely disabled premature baby requiring urgent heart surgery to save his life and the granddad requiring dialysis every 3 days! When we had a group like this, the clinic was crazy and we were running around like mad trying to keep the flow of minor cases moving whilst providing emergency care alongside. Luckily our team gelled really well and we were able to adapt to the situation when the clinic was heaving with sick people. I felt that as the 2 doctors (and I hope Elly agrees) we had a very good mix of complimentary skills and I never felt like we lost control and patients were always safe.  

We saw several cases where people just could no longer keep it together and something snapped. A young girl around 9 years old was rushed into the clinic hysterically screaming in pain and unable to stand. I rapidly assessed her and found she was very tender in her abdomen and was concerned she had acute appendicitis. We checked her vital signs and actually everything was normal. I gave her some simple analgesia (paracetamol and ibuprofen) and after 15 minutes she was up walking around smiling. She couldn’t really explain what had happened and we observed her for another couple of hours and the pain had completely resolved. One thing Elly and I talked about at the end of that shift was the importance of sitting on people like this and waiting to see what happened if it wasn’t immediately apparent there was a life threatening condition. We saw this type of presentation a few times and we could only really explain it as a psychological response to the extreme conditions they were going through and that being seen by a doctor, being reassured and maybe given any pill was enough to build the resilience back up and carry on with the journey. 

Elly and I shared out the task of going to the train station and transferring cases by ambulance to the hospital. Our first referral was a 7-year-old boy who presented with severe exacerbation of asthma. His mum stated he was on inhalers in Syria before they left but all their belongings including his medicine had been thrown into the sea by the smugglers to make the boat lighter as they crossed from Turkey to Greece. He was really unwell but it was a presentation I’m very used to dealing with in A&E in Lewisham and Woolwich. As we had nebulisers and oxygen I was able to give a significant amount of treatment to him in the clinic to see if he responded. Having experience with these kids I knew pretty early on he wasn’t going to respond and would almost definitely need referral to hospital but actually his clinical state was completely irrelevant when negotiating the referral with the family. His extended family were all travelling together and I think in total there were around 20 people linked to the child. Our Arabic Translator Hakim was amazing at mediating between the family and us and explaining the seriousness of the child’s condition. Despite the mother and father realising how unwell he was there was still severe resistance to the family being prevented from continuing with the journey. Many of the extended family wanted to know exactly how many hours they’d be kept in the camp, predictions we just couldn’t make. It was really hard as a doctor to delay referral for a child who was clearly unwell to appease the family until the point that we had everyone on board in order to make sure the family wouldn’t be separated. Even once they had agreed to go we had a hard time from the family every hour or so having to give updates and trying to stop them boarding the next bus in the morning and wait for the kid to come back from hospital. But about 9 hours later the child returned looking almost unrecognisable to when we sent him to hospital and it was one of the really great moments when he came back to the clinic to say goodbye.

Happy Mustafa back from hospital

Another patient I transferred was a desperately sick little baby who was only 2 months old and had been born just before the family left Syria. The child had a respiratory infection and was unable to feed and was in bad respiratory distress. The mum and dad and baby were travelling together with no extended members and we managed to negotiate with the hospital to keep all of them at the hospital together. They had already been admitted in Turkey for a few days during their travel and I think they knew that the child was still unwell. The mum was only 20 years old but she was so strong and really sorted the Dad out when he started talking about missing the next train. The paediatrician I referred to was an amazing old school doctor who had excellent English and was clearly very skilled. Her first action when we brought the baby in after a thorough history and examination was to give the baby a bath! I found it very weird especially as the child needed urgent IV antibiotics in my head! Anyway, she was amazing at reassuring the parents and was very empathetic offering them showers and to wash all their clothes whilst they were in patients. I thought the child would have to be admitted for at least 48 hours and the paediatrician agreed but it was nice to see the family in a safe space and all together.

The other interesting part of the job was going to the train station to collect patients who were extremely unwell. When I went to the train it was an evening train with around 1000 people arriving. The station was crazy and chaotic and there was one doctor on the station with a handful of meds making direct referrals to us in the camp if she was concerned. When I arrived the patient in question was a young man who had a very high temperature and had collapsed on the train. She had to physically take him off the train and was trying to assess what was wrong with him. Whilst I started assessing him someone started pulling my coat and asking me to see someone else. A 9-month pregnant lady was so exhausted she also couldn’t get off the train and was unable to walk. I decided neither was so sick they desperately needed to go straight to hospital and brought them to the camp. Both turned out to be fine after a period rest, observation, IV fluids and some basic meds and didn’t need referring to hospital but the whole visit to the train station gave me a different perspective.

Although it sounds dramatic I couldn’t help but compare it to pictures I’d seen of the holocaust where people were transported on trains and then taken without knowing where they were going to these heavily militarised camps. They were going to be transported to be stored in empty warehouses for an unknown period of time all clutching a handful of personal items with the hope of finally reaching somewhere safe. When I looked in the train on my way out of the station it had clearly been horrendously overcrowded, vomit on the floors and just so dehumanising. When it was suggested to think about providing a clinic on a train I was quite excited about the logistical challenge. However, seeing that situation now I feel it’s so totally inappropriate to provide care in that setting as this would further legitimise the way the crisis was being managed. People have the right to stop, rest, eat, drink, feed their babies, change their clothes, have showers and seek medical care in a calm and controlled environment whilst making this horrendous journey. The priority should not be shuttling people across your country as fast as you can so its someone else’s problem.

Sleeping overnight at the camp

A case that I got really emotionally involved in was a young teenager who had a congenital heart problem that required surgery. I wasn’t really sure why he hadn’t had the surgery as a baby but the family were very keen that he gets to Germany where he could have proper care and follow up. He was brought into the clinic having collapsed whilst waiting in the registration line in the cold. When he came in he was completely blue and short of breath. His oxygen level was 55% (normally >95% in healthy adults) and we put him on oxygen immediately. Within 5 minutes he was much better and once he’d warmed up we decided that his background oxygen level was normally around 75% which he stabilised to. 

Severely clubbed fingers (for the medics)

We worked out that the reason he had decompensated so badly was being made to stand in the cold so we wrote a medical note and went to speak to the police to ask if he could be fast tracked through the queue and not made to wait in line. After an hour or so he wanted to go back with his family and sleep in the main tent until the bus arrived in the morning so we let him go with the note to the police to ensure he wasn’t made to stand outside again. Only 30 mins later he was rushed back in, in the same condition as before. This time we decided the only way to ensure he was warm and ok was to keep him in the clinic. So we identified the whole family and managed to get access to the mother and baby container (run by another charity WAHA) to allow his 23 family members to sleep there where we would collect them from when the morning bus arrived. Early in the morning the police chief came to say him and his family needed to get on the bus now so we started waking everyone up and getting them on the bus. The chaos of trying to wake up and dress 13 children ready with all your belongings for another journey was indescribable. I was so stressed the family would miss the bus I was running around picking children up, putting their shoes and coats on and collecting them together. Even though it was only 15 or 20 minutes I was involved in helping them get on the bus I had totally adopted the stress of the family and felt fully responsible for keeping everyone together. The relief and emotion I felt when I finally got the last kid on the bus and double checked to make sure everyone was there together was a small taster of what the adults in these families must be going through at every stage.

The family in the WAHA container before they went to bed

When we did get a break in the flow of patients we sometimes took a moment to lie down for a couple of hours. It was very disorientating sleeping inside the medical tent where you can hear the movements of everyone else in the camp around. Towards the end of the first shift and definitely in all of the rest of the shifts my brain had shifted to a hyperarousal state. The smallest noise or movement inside or outside the tent and I would wake up immediately expecting a huge flow of people into the clinic. Those who know me well, know I’m prone to sleep talking and predictably I woke up Heather and Elly! One night I shouted out in the middle of the night “When does the next train arrive?!” and would only lie back down once Elly reassured me we were in the hotel I could go to sleep.

Consciously I hadn’t realised that being in a militarised environment was affecting me but I had several dreams about being shot by the soldiers or about the clinic being bombed. I found it really weird that this was my subconscious reaction as my personal interaction with the police and military was mostly very pleasant and respectful. However, we witnessed every day unnecessary shouting and some pushing/shoving the refugees as they were were boarding buses or being registered. I can’t imagine how it must feel to have fled a war zone where your life was actually threatened by militia and then have to spend every day being pushed from pillar to post by more military actors. The entire team spoke about how unnecessary it was for the police and soldiers to be so heavily armed and how just that simple presence of guns changed the entire feeling of the camp. Individual police and soldiers were very pleasant and often when the treatment of refugees was at it worse it turned out that they were being forced to work unpaid overtime or had been drafted to work without notice that morning. The camp did run “efficiently” and the flow of people was managed well but overall it was just so unnecessary to have so many physical barriers and escorting people often children, with huge weapons to just go to the toilet. 

Open access to healthcare....

I have so many more stories of individuals and families that we were privileged enough to share a small part of their journey and feel this post is becoming way too long again! One of our observations I touched on earlier was actually defining the mandate of the clinic. Our team had a very shared ethos where we wanted the clinic to be a humanitarian space and we really wanted the clinic to run as an open access self referral system. This means that if anyone wants to see a doctor they are able to and there should never be any triaging by police or military to decide if your sick “enough” to see the doctor. Trying to define the role of clinic is difficult as defining medical care is not as clear cut in this setting. Providing rest is the treatment to exhaustion, providing nappies and a space to feed the treatment for an irritable baby, rewarming the treatment for hypothermia and play the treatment for kids who have been travelling non stop for days. However, when we had acutely sick people like a lady who was maybe having a heart attack or the boy with severe asthma our clinic suddenly morphed into an A&E majors department and we went from blowing bubbles to cannulas in a heartbeat. Many health actors are stepping in to provide the humanity in this setting and actually there shouldn’t really need to be a “humanitarian space”. The whole camp should be made with humanitarian principles as a priority not the logistical issues. After all these are people fleeing war and persecution not criminals or cattle or cargo.

Another thing we talked about as a group was seeing ordinary Slovenians differentiating themselves from the state and providing that humanity to people. All the food distribution, escorting to and from the clinic and providing of new clothes, nappies etc was being managed by unpaid volunteers working with Slovenian Philanthropy. They were incredibly responsive to our presence and really amazing at trying to improve the position of the people they were helping in whatever ways they could find despite the barriers created by the system. This crisis so far will be remembered for the terrible way our state organised activities have failed these refugees and how ordinary people and voluntary organisations have stepped in to pick up the slack.

One final point I want to make is that I have noticed the softening of the media to the plight of Syrians and there seems to be accepted that Syrians have the right to flee. This is of course welcome news and vital to help apply pressure onto the government to accept more refugees. However, everyone has the right to escape persecution and claim asylum in any state. Because Macedonia’s policy is still in place, where only Syrians, Iraqis and Afghanis (SIA) are allowed to cross the border we only saw people from those countries or pretending to be from SIA countries. This means that anyone who is black is unable to pass for SIA and is returned immediately on arrival. We saw 2 Somali girls who were detained at the camp and sent to a detention centre in Slovenia despite having every right to claim asylum. The Syrians we met sure have every reason to be fleeing, but so do the Afghanis, the Somalis, the Pakistanis pretending to be Afghanis and the Iranians pretending to be Afghanis and everyone else the world over who’s countries are so fragile or poor they have no prospect of a future. People are people and we need to stop making a distinction between those who have the right to flee and those who don’t. No one would put their children and disabled mother in a boat and travel thousands of miles to Europe if there was not the hope that life would be better than where they left.

Best selfie ever.

Back in Action!

So just when I had adjusted to the fact that my time away had been cut short and I was going to have a Christmas back home, I got a call last Thursday from DOTW asking if I could come back to Slovenia on Saturday to stay one week. I don’t think I fully appreciated the reality of “being on standby” for this kind of emergency, and it took me one evening to make a positive decision to come back. I owe everything to Bob as always for constantly supporting me to make these decisions and to his family for being so understanding about me missing Christmas with them.  

Since we left 10 days ago, our team on the ground have been working tirelessly to try negotiate with the Ministry of Health to agree to a long term presence for a DOTW camp in the currently used entry and exit points but to little avail. In Dobova (the main entry point), a team from a Slovakian University has been providing medical care for refugees when they enter Slovenia from Croatia. We have been asked by the Slovakian coordinator to step in to provide some much needed respite for their team of docs and nurses so they could have time off over Christmas. When we arrived we were really unsure as to how many staff members would be remaining, what kind of clinic we’d be stepping into and how many refugees, if any, there would be to treat.

Our little team from Gornja Radgona has grown a bit. In addition to Heather, myself and Claire our stand in coordinator/data collector (whilst Titi is on holiday), we have been joined by Elly an experienced Gp from Belgium who has volunteered in the Belgian MdM clinic for a few years, Hakim our Arabic interpreter from Morocco and Ramin our Farsi interpreter from Iran. We’re staying in a time capsule from post soviet 1960’s complete with wood panelling and VERY patterned carpets and cosy shared rooms.

We got stuck straight in on Sunday and went to meet the Slovakian team quite early in the morning. The Slovakian coordinator is a fiercely efficient lady who has clearly cultivated a very functional and efficient clinic and is quite rightly protective of her operation. They have an amazing clinic that is heated with a well stocked pharmacy and good space for consultations. They have an ultrasound machine, capacity to give medicines intravenously, provide nebulisers, do ECGs and defibrillators if someone’s heart stops!

Consultation space to have some privacy

Pharmacy (bit better than our mobile one!)

Ultrasound, defibs and emergency bags

Unlike Gornja Radgona there seems to be no plan as to when refugees arrive and the medical team have to be on standby to run the clinic 24/7. The Slovaks have decided to run the clinic in 24 hour shifts so they work from 9pm one night until 9pm the next night and start 24 hours later. The clinic runs with 2 doctors and 1 nurse and sometimes final year nursing students. The reason for 2 doctors is first, to manage the numbers of refugees they are seeing in short time periods and second, to provide cover for the train station.

Refugees transit through Dobova in 2 ways. They are either brought from trains or buses to be registered at Dobova camp where they will wait an undefined period for the next bus or train. Whilst they are waiting in Dobova this clinic provides an opportunity for healthcare, food, clean clothes and toilets. There are heated tents but no formal sleeping areas as people do not tend to stay “overnight” despite arriving through the night, normally the next bus or train arrives in a few hours to take them across Slovenia. The other possibility is that they are brought by train to Dobova and are taken off one train and made to wait an undefined period on the platform of the train station before boarding the next train.

At the train station there has been a need for medical care as people wait at the platform. The Slovakian team has been providing a doctor and a paramedic with an ambulance to wait on the platform and identify anyone who needs urgent medical care and bring them to the Dobova camp or if necessary take them to the local hospital.

I’m not really sure why some people are brought to the camp for registration and why some people stay at the train stations. Its also unclear if those who are kept at the station are registered or not in Slovenia. Obviously without the possibility of visiting a camp those basic human rights are not being met and people are made to wait in the cold for the next train.

The set up of the camp is similar to Gornja Radgona but is extremely militarised and very controlled. The presence of lots of heavily armed uniformed officers creates a pretty bleak and oppressive environment not helped by the unending dense fog that only let up today. From the moment the refugees enter the camp all we hear is “quick, quick… fast, fast…” and people run from one barrier to the next scared they will be separated from their family or miss the next bus. There is SO little information sharing with the refugees and the whole system appears very dehumanising. Almost all officers wear masks and gloves and the people are just pushed through as fast as possible. The clinic is only signposted at the very first tent when the refugees enter where there is a small sign saying “if you need a doctor just ask” translated in Farsi and Arabic only. There are Slovenian volunteers and the red cross providing clothes and distributing food but its done very much on a production line and although the majority of volunteers are kind they are forced to wear gloves and masks too.

Fences to control the movements of refugees

The clinic should be open access whereby anyone who wants to see a doctor can, but I can already see there are so many barriers to care seeking. Refugees first have to feel comfortable enough to spend time visiting the clinic and not worry they will miss the next bus/train, they also need to know that there IS a clinic with doctors and nurses in it and then they have to inform one of the staff members they want to see a doctor. In order to come to the clinic they are not allowed to walk over freely and join a queue. They have to be escorted by either a volunteer or the police/military which is not the most welcoming of starts to a consultation.

Right so hopefully that has explained the context of Dobova camp, although I’m not sure I will ever fully understand what dictates the flow of people. The only people who seem to have a permanent handle on this are the police and military. Back to Sunday, we were asked to do our first shift immediately at 12pm until 9pm and the coordinator has asked us to work as an independent team in the rota she has created. When we are working the Slovak docs have time off and we hand over to them each evening.

So in our “short” shift we got stuck straight in and saw a total of 41 patients. It took a while for us to manage the flow and I would describe the way the clinic works as feast and famine. A bus arrives and there are suddenly 100 more people in the camp within a few minutes several people will be escorted to the clinic and we could get up to 10 patients arriving in 10 minutes which is explained by families or groups coming together. Then after a bus leaves it could be up to 2 hours when the camp is empty and we have no patients in the clinic at all.

Most of the patients we saw were minor illnesses such as coughs and cold but we saw several exaccerbations of asthma, diabetes and other chronic conditions. We also saw injuries people sustained during their journey, one diabetic gentleman had a poorly healing wound on his toe which happened when he was trying to get out of the boat in Greece and another young man who had been pushed to the ground by police and injured his hand in Belgrade. We saw lots of families and children mainly with coughs and colds but also one child who was rushed off a bus as it was leaving having a convulsion associated with high fever.

 

Mid consultation

We also had one lady who was 8 weeks pregnant and had abdominal pain. She was mostly well but dehydrated from vomiting which had been going on since the start of her pregnancy. The worry was she was tender in her lower abdomen. In England I would have rushed her to hospital with a possible ectopic pregnancy (where the baby grows out of the womb usually in the fallopian tube) as even though she was well at this stage it’s a life threatening condition. I was really glad to have Elly there to talk through the case with and despite neither of us having training in performing ultrasounds we had a go and Elly managed to visualise the baby bobbing away in the womb. I doubt if we had told the patient to go to hospital she would have, but regardless it shows the difficult decisions we have to make providing care in this setting. In a way not having the ultrasound would have simplified things and we would have to suggest she goes to hospital and put her through the trauma of having to decide to stop her journey or continue knowing the risk she was taking. Having the ultrasound allowed us to rule out one of the most dangerous diagnoses but we still had to be very careful explaining the warning signs of other possible diagnoses and hope that she sought care further down the line. It’s really hard to face the reality that health is not a priority for people and although they want to see a doctor moving forward and continuing their journey is the most important thing.

I’ve already written so much and as always have so much more to talk about, but to finish I want to try and describe why the clinic is so valuable. The medical care we’re giving is really secondary in most cases. Most people have minor illnesses that could go with or without the paracetamol or strepsils we give out, for a few we’re staving off serious illness for another couple of days and for even fewer we’re genuinely treating a serious condition. The key provision the clinic provides is a humanitarian space, free from “fast, fast” and guns and running to the next barrier. It’s warm and welcoming and gives people the space to breathe and think about themselves and their health and take stock of what’s happening and what they’ve been through. It’s the chance to be greeted by someone who touches you without gloves and smiles at you not from behind a mask and takes the time to listen to whatever you want to say and wishes you well. It’s simply a place to be a normal human which has been lost as the logistic problem of solving the “European refugee crisis” has been “solved”.

Doctors without Patients

The past week has been an interesting time for me, unfortunately we have not been able to see any refugees as the camps continue to be empty. We are almost certain Gornja Radgona is closed for the foreseeable future has now been empty for 12 days and shows no sign of being reopened. The reason for this has been a decrease in the flow of people coming through in general because of worsening winter conditions, Turkey’s crackdown on people crossing to Greece and the prevention of any refugees not from Syria, Iraq or Afghanistan from crossing into Macedonia.

This policy to only allow entry to Syrians, Iraqis and Afghanis has led to the accumulation of around 3000 people in a camp in Idomeni on the Greek/Macedonian border. A large fence is being constructed along the entire border to prevent people from travelling through other than at specific border points where they can control people based on nationality. Things have escalated at this camp and protests became more violent last week. Some migrants tried to rush an unguarded border point but were fought back with riot police using rubber bullets and tear gas. A young Moroccan man was electrocuted to death trying to cross the train lines. Refugees who are not from Syria, Iraq or Afghanistan have been blockading the route to prevent other refugees from entering Macedonia stating “either the border is open for everyone or it’s closed”. MdM’s clinic had to run a shortened service on the worst affected days as tensions mounted and safety of staff was questioned. Because of these protests many “accepted” nationalities are still stuck in Idomeni and the flow of “allowed” refugees into Macedonia remains reduced.

Since this policy was installed the Greek officials have put on buses to transport people from Idomeni to Athens stating they will be provided with accommodation and basic needs, but as refugees are not sure of their fate if they move to Athens many are choosing to stay in Idomeni. Over the weekend things have escalated with Greece now talking about forceful evacuations of Idomeni and request for more border police to manage the situation. There have been reports of those who left voluntarily to Athens already returning to Idomeni claiming conditions in Athens are worse.

Currently, there are only 2 camps in Slovenia that are being used, the entry point Dobova and exit point of Sentjil. The entry point is just a registration facility where people are transferred from Croatian authorities to Slovenian and then sent on buses or trains to the exit point on the Austrian border. At the exit point there is more of a delay to cross and people seem to stay overnight sometimes but usually only stay for a few hours as was the case in Gornja Radgona. 

At both of these camps there are local actors (one French NGO and the Slovakian army) providing the opportunity for medical care but our team is unsure if the medical needs are being adequately met. People from our team witnesses refugees scared to break line, as they queue to be registered, to see a doctor for fear of being separated from their family or being denied access to the next train leaving. However, given these actors have already got this space and by the Slovenian authorities measures are “meeting the medical needs” of people we are unable to work in either of these camps currently.

The other main concern with the current situation, is that unlike Gornja Radgnoa the exit point being used in Sentjil uses tents for accommodation rather than a building and with winter approaching we are worried about the inevitable freezing temperatures that will affect all those staying overnight there. We have however, been told by the civil protection authorities that if the weather does become very bad then Gornja Radgona will be reopened and used instead of Sentjil.

So in response the other MdM staff here are now trying to negotiate with the Slovenian government to be given humanitarian spaces within which we are able to set up a clinic, whilst also being on standby to react to the reopening of Gornja Radgona should a large number of refugees overwhelm the system again. The possibilities to create new spaces are to slow down registration like the Gornja Radgona set up, stop the trains at designated points to provide healthcare along the journey or consider providing healthcare on the trains transporting people.  Me and Heather made a briefing of how we think a clinic on train could be run and what issues we would need to consider. It was quite fun to think about and who knows it might go somewhere!

The negotiation of MdM with ministry of health is very complex and the government is sceptical of a sudden influx of NGOs with no benefit to the Slovenian population. One thing MdM is discussing is the possibility of providing long term care to Slovenians without health insurance as part of deal to operate in this crisis. So this work is incredibly political and not the job of a doctor and nurse looking for patients to treat! As a team we decided last Friday that until something more concrete was agreed we are being sent home on Wednesday, possibly to be redeployed to Greece or return to Slovenia if/when there are refugees back in Gornja Radgona or another space is found for us to work.

Today we had a meeting with our local partner and did a presentation outlining our work and what we have been doing. They ended up not finding any people without health insurance for the clinic they requested so again we didn’t actually see or treat anyone! We also had a positive meeting with the public health official linked to another entry point in Lendava which may be used if numbers increase again. She said that if her camp reopened they would consider MdM to provide support to the local staff to manage the health needs of refugees.

So I’m sure from all my rambling you can see that this in such an incredibly complex situation that depends on so many factors. The flow of people, the ability of the states to provide for them, the political will for states to provide care, the acceptance of local countries of foreign NGOs, the (lack of) sharing of information, the interplay between NGOs fighting for contracts, the requests of donors pushing for interventions where maybe it’s not relevant, the rapidly changing context which means long term planning is essentially impossible…..the list goes on and on.

I’ve only spent 2 weeks in Slovenia trying to identify and understand the interplay of these factors and I feel I’ve only scratched the surface. But what I know for sure is, this crisis isn’t going away, refugee’s health needs aren’t being met and EU policies on asylum and migration are directly causing human suffering and humanitarian needs. I’m heading home on weds with a head full of ideas and a desire to come back out with MdM as soon as they ask for me!

Doctor...check, nurse... check, pharmacy...check, patients.........

To even try and begin explaining what’s going on here is incredibly difficult, our information changes by the minute and by the time I finish writing this everything will probably have changed again!

I’ll start with what I know for sure. We have been here for 5 days now and we have not seen any patients yet! Our camp where we are based in Gornja Radgona has had no refugees transiting through since the 25^th November. Information from local partners and governmental officials suggest that Slovenia is now acting primarily as a corridor for refugees to be transited directly through the country from the Croatian border straight into Austria. They are only stopping to be registered at the Croatian/Slovenian border in a town called Dobova. There are some actors (not Hollywood ones) providing healthcare at this point but informal reports from refugee networks suggest that there are still vast health needs and this is before people are being shuttled onto overcrowded trains.

Last Sunday the Turkish Prime Minister struck a deal with EU leaders dangling the carrot of possibility of entry into the EU, no restrictions on visas for Turkish nationals and 3bn euros in exchange for preventing refugees from travelling into Europe. Turkish authorities have since made raids at the coast of turkey and rounded up and apprehended 1300 people aiming to make the journey by boat across to Greece. These actions along with a worsening in the weather have led to a decline in the numbers of people arriving in Greece daily (from 5000/day to hundreds). Turkey is already home to 2 million refugees and has increasingly limited capacity to manage them let along new refugees arriving daily.

Last week a statement was issued by Serbia, Croatia, Slovenia & Macedonia stating that they will now only permit entry to refugees from Iraq, Syria and Afghanistan (I'll explain in my next post why this is horrendously illegal under international law). All other refugees will not be allowed entry and in order to control this, all countries mentioned are considering or in a process of building fences to “control” the entry of migrants. This policy has directly led to around 2500 people getting stuck at the camp in Idomeni on the Greek/Macedonian border as people of other nationalities are denied entry to Macedonia. The situation is becoming increasingly tense as refugees are protesting against the unfair ruling and protests and becoming more extreme, suicide attempts, hunger strikes and some young men sewed their mouths shut as part of the protest. The health needs are great and the camp is very exposed to the elements, as winter hits the needs of these people stuck here will escalate. There are also those putting their lives in the hands of smugglers as they attempt to gain entry into Macdeonia by walking on foot through dangerous mountain roads in freezing conditions.

The situation in Calais is also getting worse. Police seem to be mounting a much more brutal response to those still trying to cross each evening and tensions between lorry drivers and refugees are escalating. The MdM clinic there is seeing regular tear gas injuries, broken bones, dog bites and lacerations from people trying to cross the razor wire. Accidental fires are becoming commonplace in the jungle as desperate people try to stay warm. However, some good news for people in Calais, an emergency court ruling has been passed obliging the Calais officials to provide urgent access to plumbed drinking water, toilets, organising the rounding up of unaccompanied minors putting them under state protection and more organisation of the camp to allow access for emergency services. We’ll have to see how this is implemented and if it brings any relief to the people stuck there.

So what have we been up to whilst all this is going on?? Well firstly we’ve been feeling very frustrated that we are a completely functioning mobile medical clinic with no patients to treat despite there being such urgent needs across Europe. Second, we have been reorganising our stock and rationalised our mobile pharmacy which sounds like a small job but took a long time to make sure everything was where we could find it. 

 

Organised!

Titi proud of our new pharmacy

Third, we have been meeting with local actors to try and gain more information about the situation and predict if there is going to be a need for our clinic in Slovenia. We have heard that another exit point (Sentijl) may start to be used again to allow processing for people on the Austrian border. The Czech army is currently providing healthcare in this camp but they are leaving on the 10^th Dec so we could potentially take over the healthcare of this camp. This camp is not as well set up as Gorna Radgona and is just tents so it’ll be a completely different set up and we could spend the next week planning logistics, finding a new place to stay and moving the clinic and tent there.

We’ve been invited along with a lot of other actors and NGOs to a meeting next Monday to explain the work that we do and see how best the Slovenian NGO network thinks we can deployed. At this meeting we’ve been asked to run a small clinic for some “migrants” that are there. We don’t have details who these people are but we think they maybe vulnerable populations in Slovenia (maybe Romani people along with very few refugees from this current crisis who have claimed asylum here). We are also going on Thursday to meet with the minister of public health in the capital along with our regional coordinator to try and see if he can agree gainfully employ us!

There is vague talk about making a clinic or running some kind of medical service on the trains that are passing through but its very early days with that one and I have my reservations about how feasible it is but could be very cool! We’ve also been eating pizza and watching films so please don’t think I’m in any way hard done by. Titi our coordinator keeps telling us to enjoy the relaxation as we will need the energy once we start but I feel like a fraud sitting around in our lovely hotel waiting for news of refugees arriving but impotent to help anyone else.  

On the one hand, I’m really glad to be here and be involved in the coordination and planning of our clinic and its really pushed me to think in depth about how complicated these situations are. I feel like I’m learning a lot and exploring all sides of how a humanitarian response is created but the overwhelming feeling is just frustration about not being able to help in a tangible way. It’s incredibly difficult for MdM to plan its human resources and when we were deployed here there were 2-3000 people transiting daily through the camp and the need was overwhelming. Its amazing how quickly things change here and how volatile the situation is. Trying to predict anything is impossible as its an entire network of countries and how one behaves affects all the others in a chain. There’s also the worry that we know there is a need here because the team before us were seeing up to 200 people a day for medical consultations and if we leave to go somewhere more urgent that need will never have any chance of being met.

There seems to be a general feeling that the Balkan governments wants the refugees in and out their country as fast as possible and in organising those logistics, officials have forgotten these are people being transported not goods. We have no concrete idea about how things are on these trains but there is a real worry about the dehumanising processes being used as European governments try to move people as “efficiently” as possible. These people urgently need some humanity and watching this beautiful sunset in Slovenia tonight I have hope we will get a chance to provide that soon.  

Responding to the European Refugee Crisis

When I announced at VERY short notice to my family and friends that I was coming to Slovenia to help respond to the refugee crisis as a clinical doctor with Doctors of the World (DOTW) I was unsure what reaction I would face.  

I have been completely overwhelmed by the outpouring of support from my friends, family, colleagues, old (as in long ago not age wise(!) teachers and strangers. I feel incredibly privileged to have been given the opportunity to use my skill set in a really tangible way to help some of these most vulnerable people and feel I’m here on behalf of everyone I know who supports this work.

I want to spend this first post explaining a bit about the work I’m here to do and my (very) limited understanding of the current situation as it stands. I feel in the 2 days I’ve been here I’ve received so much information and feel obligated to get it out there and consolidate it in my head too.

DOTW UK is part of the Medecins du Monde (MdM) international network which along with international humanitarian work has had a long term presence in Europe providing healthcare to vulnerable populations. In June this year DOTW UK launched an emergency response as the crisis worsened across Europe and made a call for volunteers to be added to a bank of staff willing to be deployed at short notice to new clinics as the need arose around Europe. I applied around August hoping to get involved before going to South Africa to work in a hospital there.

The new clinics have been set up mostly at border crossing points where there is a delay of getting people across a border. People are held in “transit centres” for a few hours (or sometimes overnight) whilst the flow of migrants is managed by the national army and police of the country the migrants are leaving. In some situations, there is no flow (like Calais) and people end up being stranded for hours/days/weeks/months/indefinitely until the border point (re)opens or a new route is established.

Now, these transit centres are NOT accommodation centres. There is a clear distinction from those countries who have agreed to house refugees (Germany) and those who have not. In Germany there are designated accommodation centres where under the protection of the Geneva Convention refugees have the right to live indefinitely until a period where EITHER the political situation changes in their country of origin and it is deemed safe for them to return OR the country they are in decides to allow people to have the right to reside as full integrated members of society in the new country OR they are sent to another country to gain residence. Whilst in these accommodation centres the refugees have rights to schooling, healthcare, shelter, meals etc, and to apply for work the same as a national resident (more on this is my second post).

Right, back to our work. At these transit centres there is the theoretical opportunity for food, shelter, clothing, showers and healthcare (you know those basic human rights) as people get backed up through bottle necks as border points try to control the flow of people.

The role I have been assigned is as the physician along with one nurse providing primary healthcare within a “mobile clinic” to those transiting through Slovenia to the Austrian border in a village called Gornja Radgona. The MdM Belgium team is coordinating the project and had set up this clinic at the beginning of November following an exploration team assessing where refugees could potentially accumulate and where best to provide care, in agreement with local partner NGOs. We are relieving one doctor and one nurse from the UK, who with their tiny amazing team, drove from Belgium with 2 vans full of medicines, equipment and a tent, set up a fully functioning mobile clinic within the transit centre created by the Slovenia government.

The Gornja Radgona transit centre has been incredibly busy with around 1-2000 people transiting through to Austria daily. The people are moved three times a day to the Austrian border accompanied by army and police around a 1km walk where they are put onto buses to be transported to the next transit centre in Austria. People on average stay a few hours and most have been travelling non stop for at least a few days and some have started their journeys months ago. There is a real need to provide care for minor illnesses, poorly managed chronic health conditions, pregnant women, young children, psychosocial problems, dehydration and infections from poor conditions and travelling along this route.

I have only been here for 2 days and trying to understand the flow of people, why and how they accumulate at various bottle necks is mind boggling. There is very little concrete information about how individual countries are maintaining their border points and how the flow will change. Quite unexpectedly after 2 weeks of over 1000 people arriving a day in Gornja Radgona, the camp has been empty for the past 3 days. Currently Slovenia is transiting migrants by placing them directly on a train from Croatia non-stop across Slovenia to Austria so the country is acting as a corridor and the transit centres are empty. The police are expecting many to arrive tomorrow or Monday, but there is no real information being shared with MdM and we hear our information second hand from UNHCR and other local actors. 

However, for the MdM team, it has been a much needed break for the outgoing group and vital time for Heather (the nurse) and I to understand and fully handover the clinic before they leave on Sunday.

I’m going to stop here because this post is already too long and if you’ve made it this far then well done! I have so much more I want to say and I’ve not seen a single patient yet so I feel this is going to be an incredibly eye opening, challenging and fascinating 6 weeks. But I’m incredibly excited to be here and Heather and I are raring to go. I want to say thanks again to everyone whose kind words have made me value this work more highly and again I feel so privileged to have been given this opportunity and hope we can make a difference here. 

Heather and I raring to go in snowy Slovenia