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OBSTACLE

COURSE

TO EUROPEA POLICY-MADE HUMANITARIAN

CRISIS AT EU BORDERS

December 2015

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CONTENTS

GLOSSARY

Asylum seeker :A person who seeks safety from persecution orserious harm in a country other than his or herown and awaits a decision on the application forrefugee status under relevant international andnational instruments.

Migrant:a person who is outside the territory of the Stateof which they are nationals or citizens and whohas resided in a foreign country for more thanone year irrespective of the causes, voluntary orinvoluntary, and the means, regular or irregular,used to migrate.

Refugee :either a person who, owing to a well-foundedfear of persecution for reasons of race, religion,nationality, political opinion or membership of aparticular social group, is outside the country ofnationality and is unable or, owing to such fear,is unwilling to avail themselves of the protectionof that country, or a stateless person, who,being outside of the country of former habitualresidence for the same reasons as mentioned

before, is unable or, owing to such fear, unwillingto return to it.

NB : As a medical humanitarian organisation,Médecins Sans Frontières (MSF) does not operateany distinction between people on the basis of theirlegal status. Our assistance is based on medicaland humanitarian needs alone. Generic legalterminologies will never sufficiently reflect thecomplexity of our patients’ migratory movements, thetrauma they have suffered along the way and theirneeds for protection and assistance. The terms usedin this report are without prejudice to these realities.

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EXECUTIVE SUMMARY

The world currently faces its largest globaldisplacement crisis since World War II, withapproximately 60 million people currentlydisplaced due to conflict, persecution anduntenable conditions in their home country.Whilst foreseeable, Europe is still reeling inshock from the sheer numbers of refugeesand migrants – approximately one million –who have crossed its borders in 2015.

It will be remembered as the year in

which Europe catastrophically failed in itsresponsibility to respond to the urgent needsof assistance and protection of hundreds ofthousands of vulnerable people. Not onlydid the European countries and its memberstates collectively fail to address the urgenthumanitarian and medical needs of refugeesand migrants arriving at external or internal EUborders, but the European Union’s deterrenceand anti-immigration policies – developed overthe last 15 years and further strengthened in2015 – have increased the demand for migrantsmuggling networks and pushed peopletowards ever more dangerous routes which jeopardise their health and lives. These policieshave largely contributed to the patterns of thereception crisis we are witnessing today : withthose desperate to come to Europe forced tocross the sea and southern EU countries failingto respond to their needs.

Facing razor wire fences, closed bordersand intimidating soldiers and police forcesfrom Turkey through most of the Balkans;highly dangerous sea crossings to Italy orGreece; squalid and inhumane receptionconditions; and complicated and everchanging registration procedures, thousandsof men, women and children fleeing conflictand desperate conditions have had to faceanother obstacle course, this time throughEurope. Countless meetings, conferences andplans have been organised by the EuropeanUnion and its member states throughout2015. Despite this, most states have been

unwilling or unable to provide assistance tothe refugees and migrants who make it intothe European Union. As of 3 November 2015,14 member states had collectively made 2,284places available out of the 160,000 Europeanrelocation pledge and only 86 people hadeffectively been relocated from Italy.

The traditional state and UN-sponsored aidsystem has also struggled to adequatelyrespond to people’s needs. Instead, civil

society and volunteer groups, better able towork around administrative, institutional andpolitical blocages, have emerged as key toproviding refugees and migrants with essentialservices throughout their journey. At thecore of these non-state activities has beenan overwhelming upsurge of solidarity fromcitizens across the world volunteering theirtime, donations and money to assist the tensof thousands of refugees and migrants in need.

As an emergency medical humanitarian organ-ization, Médecins Sans Frontières (MSF) scaledup its operations in Europe throughout 2015and focused on setting up mobile responsesto attend to the needs of these unprecedentednumbers of people on the move.

Never before has MSF had so many projectsin Europe, never before has MSF decided tomobilize three search and rescue ships atsea to save lives, and never before has it beenmore urgent for European governments tostep up to their international obligations andassist these people whose lives are at risk.

Indeed, the situation at Europe’s bordersin 2015 has cast a spotlight on a number ofhighly inconvenient facts that European gov-ernments have been trying to ignore for years:

• Closing borders does not stop people mov-ing, it simply shifts their routes;

• Deterrence policies have direct detrimen-tal humanitarian and medical impact; and

response to refugees and migrants desper-ately seeking its protection and assistance.

The EU and European states are stronglyurged to:

• Swiftly provide safe and legal channelsfor people seeking asylum, in particularallowing asylum seekers to apply for asy-lum at external land borders, includingthe Evros land border between Turkeyand Greece. This also includes making

wider use of legal entry schemes, suchas (for example) family reunification, hu-manitarian visas, simplified visa require-ments, resettlement and relocation.

• Create legal migration pathways to de-crease the demand for irregular migra-tion and smuggling networks.

• Create an ambitious search and rescuemechanism to save lives at sea. Thisoperation should proactively search forboats in distress as close to departurepoints as possible and should be accom-panied by pre-identified disembarkationpoints where humane disembarkationprocedures, including adequate recep-tion conditions, medical care and vulner-ability assessments, are in place.

• Invest in reception according to EU stand-ards instead of deterrence measures only.Europe must move away from a fortress

approach to a reception approach de-signed to address the needs and specificvulnerabilities of people arriving at itsborders, in particular their medical andmental health needs.

• In the absence of a functioning commonEuropean asylum system, invest more am-bitiously in intra-EU relocation schemesand the creation of safe passage throughthe EU.

• Put an end to acts of violence and abusefrom state authorities and criminal groups.

• Increasing humanitarian aid to camps inLebanon, Turkey or Jordan, even if urgentlyneeded does not absolve EU member statesof their responsibilities to receive, assistand protect refugees within EU territory;and it will not stop people seeking safety inEurope for complex reasons

In denying vulnerable people dignified recep-tion conditions, and blocking and pushing backpeople based on their nationality rather thanvulnerability and risk of persecution, Europe-

an states have eroded the very foundations ofinternational refugee and human rights law.

With a new year ahead and a few months be-fore another potential peak in arrivals, Europeand its member states have the opportunityto right the wrongs of 2015. Europe must dis-mantle its obstacle course and provide assis-tance and safe, legal passage to refugees andmigrants fleeing desperate conditions.

This report tells the stories of men, women,children, the elderly, the sick and the disa-bled, travelling alone or with their family,fleeing war, persecution or extreme povertyand seeking refuge and a better life in Europe;people who were left with no other choice thanto run the obstacle course to Europe. It high-lights how the EU’s response so far has notonly failed to respond to the urgent humani-tarian and medical needs of these vulnerablepopulations, but has also contributed to the

worsening of their situation, with a some-times tragic impact on their health and lives.

The report spells out that Europe cannotcontinue to count on the deadly sea cross-ing, fences and poor reception conditions toact as a ‘filter of deterrence’. The currentnarrative and policies cannot hold. As insta-bility continues to rage across Syria, Libya,Iraq and Afghanistan, the EU and Europeangovernments must shift their current poli-cies and provide a humane and humanitarian

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QUANTIFYING AND QUALIFYING THE MOVEMENT OF PEOPLE :

• Between 1 January and 31 December, an estimated 1,008,616 people fled to Europe

• 84% came from refugee-producing countries, with 49% from Syria, 21% from Afghanistanand 9% from Iraq

• 17% were women and 25% were children under the age of 18

HEALTH IMPACTS OF EUROPE’S MIGRATION POLICIES :

Between 1 January and 15 December 2015, MSF teams provided just under 100,00 medicalconsultations to refugees and migrants on its search and rescue vessels in the MediterraneanSea, in Italy, Greece and throughout the Balkans. Between May and December 2015, MSFrescued and assisted 23,747 refugees and migrants at sea. They bore witness to and treatedthe physical and mental health consequences of the terrible journeys and the lack of basicassistance, as well as injuries and mental health trauma sustained by violence. Most of thepathologies treated by MSF medical teams could have been easily prevented if a safe passageand reception up to humanitarian standards had been put in place by EU states.

Our medical teams in Greece and Serbia treated 12,214 patients for trauma related conditions,which represents 18% of all medical consultations in these two countries. Among the 408 mostsevere trauma cases, 70% of these patients reported physical violence, robbery or verbal abuseand intimidation experienced during their journey.

MSF’S MOBILISATION ON MIGRATION IN EUROPE :

In 2015, MSF spent an estimated 31.5 million euros and mobilised 535 staff to respond to theneeds of refugees and migrants in Europe :

• 45 MSF staff and 11.5 million euros were mobilised to carry out search and rescue operationson three vessels in the Mediterranean Sea.

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

KEY FACTS AND FIGURES

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INTRODUCTION :A POLICY-MADE HUMANITARIAN CRISIS

“We fled to Europe for the security of thechildren. To make sure they are safe andhave access to good education. Becausethere is nothing left in Syria. My entiretown is destroyed. But if I had knownthat it’s so hard to reach Europe, I wouldnever have sent them. I’d rather havedied in Syria than to go through this. Ithought people in Europe would treat uswell. Because of all the difficulties onthe road, some of us gave up and wentback to Syria. They are dead now. In total,I was arrested 33 times. I was thrown inprison in Greece, in Macedonia, in Serbia,in Hungary. Why? I don’t understand. I didnothing wrong. I did not steal nor kill. Iflee death, but I only find death. My futureis the future of my children. If only I knewwhere they are...”

Syrian man living alone in a forest after he lost track ofhis wife and four children, winter 2014, Serbia.

In 2015, just over a million people risked their lifeto reach Europe from Africa, Asia and the MiddleEast; 84% of them came from the world’s top 10refugee-producing countries. While the officialdiscourse in Europe has tended to present thecontinent as overwhelmed by an ever-growingwave of migrants and refugees, their numberaccounts for less than 0.02% of Europe’s total

population. Indeed, the vast majority of peoplefleeing conflict zones are internally displaced orlive in neighbouring countries. In 2014, Turkey,Pakistan and Lebanon alone hosted one third ofthe world’s refugees1. In Lebanon, a country witha population of 5.8 million, refugees representalmost 30% of the population.

As we reflect back on 2015, the year willundoubtedly be remembered in Europe asdominated by a ‘refugee crisis’ driven byexternal forces. Yet the humanitarian crisis thathas unfolded on the borders of the EU is theresult of no natural or unforeseen disaster. Itis in large part a policy-driven crisis sustainedby the failure of the European Union to putin place adequate and humane policies andresponses to deal with this unprecedented butin many ways foreseeable movement of people.For years, the EU and European governmentshave chosen to invest years ago in measuresaimed at systematically sealing off borders and

deterring refugees and migrants from seekingsafety in Europe. These policies include thebuilding of fences at external but also internalEU borders, stricter border controls aiming at‘fighting’ irregular migration, the containmentof migrants and refugees in countries of firstarrival or in transit countries outside of the EU,the increased use of immigration detention, andchronic substandard and insufficient receptionconditions in countries of first asylum, primarilyin Italy and Greece.

As a result, refugees and migrants, many fleeingwar and persecution and in search of assistance

and protection, have faced further violence,arbitrary detention, ill-treatment, extortion,sexual violence, human trafficking, push-backsat borders, and inhuman reception conditionsin countries of first asylum. With land bordersinto Europe (namely the Spain-Morroco, Turkey-Bulgaria and the Turkey-Greece borders) mostlysealed off, the only possible entry to Europe

for most is across the sea. Whilst the majorityof people reached Europe through the CentralMediterranean route (mainly Libya to Italy) in thefirst half of 2015, the movement of people shiftedto the Eastern Mediterranean route (mainlyTurkey to Greece) from July 2015, with an averageof 5,000 people arriving every day on Greekshores in September 2015. As of 31 December,at least 3771 people had died whilst attemptingthe sea crossing to Europe in 2015. Today morethan ever, the EU and European governments’restrictive policies are jeopardising the right toseek asylum and putting refugees and migrants’health and lives at risk.

For the last fifteen years, MSF has been workingin European Union (EU) countries, providingmedical care and humanitarian assistance torefugees, asylum seekers and undocumentedmigrants. In the last year and especially sincethe summer of 2015, the organisation has had todramatically scale up its operations in Europe.

The need for MSF, as an international medicalhumanitarian organisation, to conduct search andrescue operations at sea and to provide assistanceat Europe’s entry points is a telling indictment ofthe lack of adequate state assistance currentlyavailable for these vulnerable populations. Neverbefore has MSF had so many projects in Europe,and never before has it decided to mobilise searchand rescue vessels at sea to save lives. Never hasit been more urgent for European governmentsto step up to their international obligations andassist these people whose lives are at grave risk.

While some new and positive measures havebeen put forward by the EU and its memberstates, such as proposals for the relocation andresettlement of asylum seekers and refugees,and whilst countries such as Germany activelywelcomed over a million refugees and migrantsin 2015, Europe’s response has been too slow andinsufficient. As for the relocation and resettlement

schemes, these have not been mandatory andstates have mostly refused to participate. As of3 November 2015, 14 member states had made2284 places available out of the 160 000 Europeanrelocation pledge and only 86 people had effect ivelybeen relocated from Italy. As winter sets in, thehealth and lives of thousands of women, childrenand men are more than ever at risk, and the EU’spolicies and actions are all the more inadequate.

This report tells the stories of men, women,children, the elderly, the sick and the disabled,travelling alone or with their family, fleeingwar, persecution or extreme poverty andseeking refuge and a better life in Europe;people who were left with no other choicethan to run the obstacle course to Europe.This report highlights how the EU’s responseso far has not only failed to respond to theurgent humanitarian and medical needsof these vulnerable populations, but hasactively contributed to the worsening of their

situation, with a sometimes tragic impact ontheir health and their lives. This report showsEurope cannot continue to count on the deadlysea crossing, fences and poor receptionconditions to act as a ‘filter of deterrence’. Thecurrent narrative and policies cannot hold.As instability continues to rage across Syria,Libya, Iraq and Afghanistan, the EU must onceand for all acknowledge the human cost ofits policies and shift its response to provideassistance, protection and adequate receptionto refugees and migrants desperately seekingits protection and assistance.

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THE EUROPEAN UNION’SASYLUM FRAMEWORKAND POLICIES

Throughout 2015, the EU’s response to the increased flow of refugees and migrants arriving atits shores has been framed by the existing general framework of the Common European AsylumSystem, and by additional agreements and plans developed mainly from May 2015. As detailedbelow, these have predominantly focused on blocking the flow of arrivals rather than addressing the

humanitarian and protection needs of refugees and migrants arriving in Europe.

A GENERAL FRAMEWORKFOR ASYLUM IN EUROPE :THE COMMON EUROPEANASYLUM SYSTEM

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

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

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

DEVELOPMENTS IN 2015 :THE EUROPEAN AGENDAON MIGRATION ANDITS IMPLEMENTATION

Faced in 2015 with a growing number of peopleseeking safety and protection in Europe, EUinstitutions adopted a number of plans andpolicies. In May 2015, the European Commissionpresented its new European Agenda onMigration, putting forward immediate responsesand longer-term policy changes for the so-called‘emergency situation’ at its borders3.

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Two implementations packages, on 27 Mayand 9 September 20154, as well as severalexceptional summits and ministerial meetingshave been organised since, aimed at adoptingsome of the agenda items on migration andother key measures. A meeting of EU Heads ofState on 25 October 2015 on the Western BalkanMigration Route also agreed on a 17 pointplan of action, focusing on better coordinationbetween countries, the strengthening of bordermanagement to “slow down the flow”, improvedshelter and tackling smuggling and trafficking5.

With regards to relocation and resettlement,more concrete proposals were made in July2015, when the Justice and Home Affairs Co uncilagreed to resettle 22,504 displaced personsin clear need of international protection from

outside the EU6

. On 14 and 22 September 2015,the Extraordinary Justice and Home AffairsCouncil and the Extraordinary Home AffairsCouncil agreed on the relocation of 160,000asylum seekers from Italy and Greece to otherEU member states7.

Another area that has been prioritised in recentmonths has been returns. On 9 September2015, the EU Action Plan on Return was putforward in order to increase the capacity of themember states to return ‘irregular migrants’.Further proposals have included the creationof a dedicated return office within Frontexbefore the end of the year that would “havethe right to organise joint return operations onits own initiatives, to promote acceptance bythird countries of an improved return laissez-passer for return purposes, to further increaseincentives for third countries and to committo returning 400,000 failed asylum seekers” 8.In December, this idea was reinforced in theEuropean Commission’s proposal to create anew European Border and Coast Guard agencyreplacing FRONTEX by a more autonomous andefficient body9. 

In terms of funding, the EU and its memberstates have focused on providing resourcesto three funds, the Syria Trust Fund 10, theEmergency Trust Fund11 and the Refugee Facilityfor Turkey12  as well as resourcing the WFP,UNHCR and a number of other programmes.ECHO’s humanitarian aid budget of €324million in 2015 also includes support for Syriaand refugees in Lebanon, Jordan, Turkey, Iraq

and some Western Balkan countries since July2015. It cannot however fund the humanitarianresponse in key European affected countries,most notably Greece.

Finally, two diplomatic initiatives  involvingEU member states are important to highlight.First, is the Valletta Conference on Migrationof 11-12 November 2015, attended by EU andAfrican States concerned by migration andaimed primarily at addressing the root causesof migration in departure countries, tacklingthe smuggling and trafficking of migrantsand increasing cooperation on return and re-admission13. Second, is the EU-Turkey JointAction Plan. In exchange for a Europeancommitment to a €3 billion Fund to addressthe humanitarian situation in Turkey and the

possibility of faster accession to EU membershipstatus, Turkey committed to increased effortsto stem the flow of migrants across its territoryto Europe and cooperate on the re-admission ofirregular migrants14.

While some new and positive measures havebeen put forward by the EU and its memberstates, such as proposals for relocationfrom Italy and Greece and resettlement ofasylum seekers and refugees, much of theirresponse to date has been largely insufficientand driven by a border-control agenda andthe willingness to stem the flow of arrivalsin Europe, rather than addressing the urgentneeds for assistance and protection of peoplefleeing to Europe. Indeed, the objectives ofFrontex’ operations Triton and Poseidon andof operation EUNAVFOR’s are to strengthenborder controls and disrupt smugglingnetworks, rather than saving lives at sea oroffering safe and legal passage for peopleto seek safety and protection in Europe15.Other priorities, including voluntary andforced return and funding the humanitarianresponse in areas of departure, fail toaddress the complex reasons for people’sflight ; fail to respond to people’s urgent needfor assistance and protection in Europe; andfail to offer people safe and legal ways toseek the assistance and protection they sodesperately need.

THE EUROPEAN AGENDA ON MIGRATION AS DEFINED BY THE EUROPEANCOMMISSION AND ADOPTED IN MAY 2015

EMERGENCY MEASURES

• The budget for Frontex Poseidon (Greece) and Triton (Italy) joint operations was provided an additionalÐ26,8 million for 2015-2016 and the area of operation of Triton was extended to 138 nautical milessouthward of Sicily’s coasts.

• The new concept of ‘hotspots’ was created to swiftly identify, register and fingerprint migrantsand refugees arriving in frontline member states and coordinate relocations or returns. It involvesthe cooperation of the European Asylum Support Office (EASO), the EU Border Agency (Frontex),the EU Police Cooperation Agency (Europol) and EU Judicial Cooperation Agency (Eurojust) withthe authorities of the frontline member state.

• On 22 June, Common Security and Defence Policy (CDSP) operation “EUNAVFORMED-Sophia ”was launched in the Mediterranean Sea. The aim of this military operation is to “undertakesystematic efforts to identify, capture and dispose of vessels as well as enabling assets used orsuspected of being used by migrant smugglers or traffickers”.

• A commitment to relocation (160.000 asylum-seekers) and resettlement (20.000 refugees) ofpeople in need of international protection.

LONG-TERM STRATEGY

• Reducing the incentives for irregular migration

• Saving lives and securing the external borders

• Developing a strong asylum policy (including through the full implementation of the CommonEuropean Asylum System – CEAS)

• Defining a new policy on legal migration

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“When we were on our way, we wentthrough a tragedy worse than the waritself, that of being a refugee : that ofgoing through dangerous stages and notfinding a country to welcome you.”

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

“Before the war, we had a good life.But during the war I have seen awfulthings. Disaster. That’s all I can say. Ihave suffered beatings and torture. Foralmost seven months, the army keptus in isolation without food and contactwith other people. I saw children dyingfrom hunger. I saw people dying becausethey could not receive their medication.”

29 year old man from Syria, on board the MSFBourbon Argos search and rescue vessel

“I never thought of leaving my country,or fleeing to Europe. There is no betterplace than home but we had no choice.”

Palestinian-Syrian man with his wife and their youngson, on board the MSF Bourbon Argos search andrescue vessel

“In Afghanistan I was running apharmacy and teaching at a local school.One day, some of the men in the villagecame to me, accusing me of teachingChristian ideas to the children. They said,‘You’re not a true Muslim, very soon youwill be beheaded’. Then, at the sametime, I discovered that everything in mypharmacy had been smashed to piecesand that my father had disappearedwithout any explanation. It’s now aboutthree months since we last heard fromhim, and I don’t know if he is dead oralive. For this reason I decided to escapefrom Afghanistan, while hiding my family

in another part of the country.”26 year-old Afghani man, Subotica, Serbia

“I have been travelling for about sevenmonths. There are so many problemsin Eritrea, especially the governmentpolicies. You need to serve in the armyfor a very long period with no salary.How are you supposed to eat? Also youare forced to do work linked to what youstudied. There was no work for me so I

STEP 1 : FLIGHT

In 2015, 1,008,616 people fled to Europe, fleeing their home countries and seeking safety and a betterlife16. Whilst states have been quick to categorise people arriving on their territory as “irregular” or“economic migrants” on the one hand and “refugees” on the other, the reality of this mixed flow is farmore complex.

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

THE OBSTACLE COURSETO EUROPE

Skip yourturntwice   ClosedborderCheckpointWar Violence

Violence

Noassistance

DETENTION

Roll thedice again

Roll thedice again

Refugeecamp

Noopportunities Smuggler

Smuggler

ONTHE MOVE

ONTHE MOVE

LIBYA

Leavethegame

YOUHAVE BEEN RESCUED

GREECE  Youmadeit

toEurope

MACEDONIA

Frostbite

SERBIA

ITALY

HUNGARY

GotoItaly

ASYLUM

Littleassistance

Littleassistance

Fakedocuments

YOUDROWNED

LEBANON

TURKEY

EGYPT

Starthere

SYRIA

Smuggler

SmugglerClosedborder Skip yourturnonce

BANDIT

Closedborder

Closedborder

Skip yourturnonce

BANDIT

Harshweather   Smuggler Skip yourturnonce

BANDIT

ClosedborderRoll thedice again

Roll thedice again

Roll thedice again

ONTHE MOVE

ONTHE MOVE

ONTHE MOVE

Littleassistance

Fakedocuments Closedborder

Closedborder

Closedborder

Closedborder

Closedborder

SmugglerSkip yourturntwice

DETENTION

Littleassistance

Skip yourturntwice

DETENTION

Skip yourturntwice

Skip yourturntwice

DETENTION

DETENTION

SmugglerLittleassistance

Littleassistance

Fakedocuments

Roll thedice again

Roll thedice again

ONTHE MOVE

ONTHE MOVE

Roll thedice again

ONTHE MOVE

Noopportunities

Noopportunities

Noopportunities

Noopportunities

1718

8   97654321

11   101213141516

26   2725242322212019

29   2830313233343536

44   4543424140393837

47   4648495051525354

62   6361605958575655

65   6466676869707172

80   8179787776757473

THIS IS NOT A GAME:The Life and Death

Obstacle Course to Europe

Syria has been consumed by war since 2011. At

more than 4 million, Syrians today are the world’ssecond largest refugee community. To escapedeath, detention, and misery, they have to risktheir lives in a long and dangerous path to safetyand asylum. It is the ultimate life and death obsta-cle course.

This is not a game.

MSF runs medical activities in Syria, its neighbor-ing countries, and Europe providing health servicesand assistance to vulnerable communities. MSFworks in health, relief, and reception centers in andalong the borders of Tunisia, Italy, Greece, Serbiaand others. MSF-operated search-and-rescueboats in the Mediterranean have rescued more than15,000 people. Thousands more make the journeyfor safety every day.

War: Airstrikes,barrelbombs,hell canons,carbombs, chemicalattacks,shelling.

Refugeecamps:Located inSyria’sneighboring countriesofTurkey,Jordan,Iraq,and informaltented settlementsinLebanon.

Transportation:Planes,trains,buses,cars,boatsand feetcanall beused toreachasylum.

Rescued:Rescuebycoastguards,fishermen,orMSF andotherNGO search-and-rescueoperations.Somemodest aid isprovided beforethe

 journeycontinues.

Checkpoint:Militaryorsecuritycheckpoint,whereonewaitstopass,stay,or retreat.

Noopportunities:Cultural,linguistic,political,social,financial,legal barriersthatlimita person’sabilitytonurture afutureina new place.

Assistance:Food,medical,and financialaid provided byinternational and localorganizations,hostcommunities,and othersupportnetworks.

Bandits:Thievesorpirateswhotargetrefugeesduring theodysseyacrossseaand land,commonlydemanding moneybeforeallowing the

 journeyto continue.

Violence:Anyactsofviolencecommittedbyauthorities,rebels,smugglers,bandits.

Smugglers:Exceedinglybecomingmoreorganized inbringing migrantsandrefugeestoEurope.Sometimestheychargethousandsofdollars,othertimesthey resorttoexploitation,violenceorblackmail.

Closedborder:IncountriesneighboringSyria orin Europe,official bordersareincreasinglybeingclosed restricting themovementofpeo pleand forcing manytofind alternativeroutes.

Harshweather:From frostbitestoheatstrokes,harshweatherconditionsarea majorobstacletoovercomeformigrantsand refugeesastheymove throughmedleyofgeo graphicenvironments.

Detention:Duetolackofdocumentationorasa form ofexploitation.

Drowning:Thousandshavedrowned intheMediterraneanastheyattemptto reachEurope.The boatseithercapsizefrom theweight,massivewaves,orsimplysunk bysmugglers

Fakedocuments:Fakedocumentsareillegal buttheycan beobtained withtherightconnectionand capital,allowing theuser tocontinuethejourney.

Asylum:Safe-zonesinwhichthemigrants andrefugeesfinallyreceiveofficial documentsandareallowed shelter,properaid and reliefservices,and areprovided withwaystostarta new life.

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As result of the bad living conditions approximatelyone-third of the people assisted by BourbonArgos were suffering from scabies, a skin diseaserelated to overcrowding and unsanitary livingconditions.

“We come from Nigeria but we livedin Libya for four years where we hada normal life, working and living alltogether. One day we (the family) wereinside the house and some guys came inwith a gun, they threatened us and theytook my husband, they tried to kill me.In the end, they left me and my children,but we couldn’t find peace there. Wehad to hide. We were hiding all the time

and we couldn’t come out. The guyscame back and we were scared. We hadto move away. We went to the shorebecause we needed to get to the boats. Ihave my children and I had to save them.I knew if I could leave, I would havepeace. That’s why I took my children andwe ran away, joining the boats.” 

 

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

“I stayed three months in Tripoli. I haveno words to describe my life there. It’sthe worst place in the world. They treatedus like animals. They separated womenfrom men and every day they took one ofus to quench their lust. Who wants to stayin Libya under these conditions? I don’twant to be abused again! So we had no

choice. It’s true, we knew that we coulddie at sea, but it was our choice.”

Woman from Eritrea, on board the Bourbon Argossearch and rescue vessel, July 2015

Far from straightforward, people’s reasonsfor fleeing are very complex and cannot bedetermined by their nationality alone. Thelegal pathways enabling them to find safety,protection, and respect for their fundamentalrights are being cut off, leaving with them littlechoice but to take dangerous routes, puttingthemselves at risk of further danger and abuse.

was put in jail for no reason. I was therefor months, and did not know how longI would be in prison, so I escaped mycountry in a lot of fear. I have a big familyand my mother is sick so I have to finda way to take care of them. The militarycame to my family when I had escapedand threatened that they all would beput in prison if they did not respond, orgive them money. As a human being youare supposed to have rights. In Eritreayou have none.”  

25 year old Eritrean man, on board the MY Phoenixsearch and rescue vessel, May 2015

A second important point is that people’sreasons for wanting to reach Europe arecomplex and their need for protection cannot beassumed based exclusively on their countriesof origin. People’s individual stories, theirvulnerabilities and possible persecution cannotbe understood without a proper assessment oftheir unique situation. In addition, some peoplewho did not have specific protection claimson leaving their country have since become inneed of protection because of the exploitationand violence they suffered during their journey.It is therefore crucial that all people seekingasylum have the right and the opportunity to doso without discrimination.

This is most certainly the case in Libya wheremany asylum seekers and migrants spend longperiods of time, either earning money or waitingfor a break in the weather before braving theseas to Europe. Aboard MSF’s three search andrescue vessels our teams have treated patientswith physical signs of mistreatment during their

transit in Libya and heard hundreds of stories ofexploitation, torture and rape. Of 125 interviewsconducted by MSF teams in October 2015,92% of people reported having been the directvictims of violence in Libya, with nearly 100%reporting having witnessed intentional violenceperpetrated against other asylum seekers andmigrants. Specific accounts include witnessingbeatings, murders, and sexual violence. Closeto half of the people interviewed reported havingbeen taken against their will and held in shortor long-term detention in formal or informalcentres in Libya, some of them multiple times.

“European countries […] have expressed sympathyand willingness to receive [Syrians] as refugees

of war, but what kind o f reception and on whatconditions? They are willing to take us in, yet we arenot allowed to go on planes to reach them, we are notallowed to reach them by sea, or even land, in a legalway, so what then? The message is crystal clear;we basically have to go through hell and face deathin order to get there... […] The question is whetherwe’ll get there or end up being buried at sea – it alldepends on luck.”

Syrian woman and m other of four children, in a letter addressed toMSF in Greece, February 2014.

STEP 2 : CROSSING THE SEA

ZARZIS

BOURBON

AROGS

MY PHOENIX

DIGNITY I

SICILY

ROME

SID

BELGRAD

PRESEVO

IDOMENI

LESBOS

SAMOSATHENS

DODECANESE

ISLANDS

MSF PROJECT LOCATION

SEARCH AND RESCUE BOAT

RESCUE OPERATION

MIGRATION ROUTE

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“We came down to the water. We werewearing heavy winter clothes. I’m rathera good swimmer but my wife isn’t. Andmy son is only a year and a half old. Wegrabbed a lifebuoy and kept swimming.Our woollen and leather clothes weregetting heavier and we got tired. I startedto scream. After a long while, some youngboys came back to help us out. It wasn’tfar to the shore – some 150 metres – butwe could have easily drowned with theweight. We were in the water for an hour.That’s one hour I will remember the restof my life. Imagine how difficult it is tohave your son in your arms and not be

able to carry him anymore. I was on theedge of letting both of us go deep down.Those were terrible moments that I can’tdescribe. I still cry when I rememberwhat happened.” 

Syrian man with his wife and their young sonaboard the Bourbon Argos search and rescuevessel, August 2015

As more people have taken to the sea the numberof deaths continues to increase. In 2015, 3,771people were registered as having died at sea,which surpasses the previous record 3,400 liveslost at sea in the year 2014.

In late 2014, the EU and Italy decided to discontinueMare Nostrum, a large rescue-at-sea operationled by the Italian navy in the Mediterranean thatrescued over 170,000 lives. EU efforts wereinstead diverted towards reinforcing the Frontexoperations Triton and Poseidon, which are mainlyaimed at strengthened border management (see

footnotes 9 and 10).

Boat crossings began rising from March 2015,and 1,308 people died or went missing at seain the single month of April 201525. Faced withthis growing number of people attempting thedangerous sea crossing, and with a clear lack ofsearch and rescue (SAR) resources at sea, MSFdecided that preventing thousands of peoplefrom drowning had become a humanitarianimperative. Within six weeks, it was operatingthree search and rescue vessels in theMediterranean Sea.

A. THE PERILOUS SEA JOURNEY

Taking advantage of the fact that migrants andrefugees cannot use safe and legal routes to e nterEurope17, ruthless and elaborate smugglingnetworks have developed in countries includingLibya and Turkey. Since refugees and migrantsmost often cannot return home because theirlives would be at risk or because they do nothave travel documents, their only option leftis to put their lives at risk on an overcrowdedboat in the Mediterranean Sea, hoping they willmake it to the other side.

Of the more than 1 million refugees andmigrants arriving in Europe by sea in 201518,the majority travelled through the easternMediterranean route from Turkey to Greece.Between 1 January and 31 December 2015,

851,319 people arrived in Greece by sea. InAugust and September 2015, an average of4,000 people were arriving on the Greek islandsevery day19. This increased further in October2015, with the average number of daily arrivalsreaching 6,00020, of which 20% were childrenand 14% women21.The month of October 2015accounted for 33% of the total arrivals in 2015. 22 

The central Mediterranean  route, from NorthAfrica (most often Libya) to Italy, was the secondmost common migratory route for reachingEurope by sea in 2015. Taken mainly by peoplefrom Eritrea, Syria, Somalia and other sub-Saharan African countries, it is considered themost dangerous23  route. As of 31 December2015, the UNHCR estimated that 153,600 peoplehad arrived in Italy by sea in 2015 24.

MSF AND GREENPEACESEA-ASSISTANCE OPERATIONSIN THE AEGEAN SEA

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

safe haven in Europe .

Between 7 and 28 December 2015, 6,055people were assisted as part of 143interventions –people 455 were directlyrescued and 5600 people were guidedor towed to safety. MSF medical teamsat landing point treated 96 people in thefirst 5 weeks of activities, of which 30 werereferred to hospital for f urther assistance,mainly for trauma.

MSF TRAINING ACTIVITIESIN TUNISIA

MSF has also been working in Tunisia  tohelp strengthen the capacity of Libyan andTunisian authorities and NGOs to cope with

emergency situations at sea. In the coastaltown of Zarzis in Tunisia, our teams havebeen organising training in dead-bodymanagement for fishermen from Zarzis,Ben Gardane and Ras Ajdir as well as forNGOs (including the Libyan Red Crescent)26.Civil Protection authorities and Libyanand Tunisian coastguards have also beentrained and MSF has provided fishermenand local authorities with rescue equipmentincluding first aid kits, protective material,clothing, life vests and body bags.

MSF SEARCH AND RESCUEOPERATIONS IN THEMEDITERRANEAN SEA

1. The MY Phoenix : run jointly with theMigrant Offshore Aid Station (MOAS), theMY Phoenix was in operation from 2 Mayuntil 22 September 2015. On board weresix MSF staff working in collaborationwith MOAS’ specialist and experiencedSAR crew. The three person MSFmedical team had the capacity to providelifesaving emergency medical care aswell as primary health care and couldrefer cases in need of hospitalisation tomainland Italy by helicopter.

2. The Bourbon Argos : Operational between9 May and 31 December 2015, the BourbonArgos could carry 500 people and had crewof 26 SAR specialists and medical staff.Several containers house activities ondeck, including emergency, consultation,an observation rooms, sanitary facilities, astock room and a morgue.

3 The Dignity I : Operational between 13June and 13 November 2015, the Dignity1had a capacity of 350 people and a crewof 18 medical staff and SAR experts.The hospital on board included eighthospital beds, a small clinic equippedwith essential medicines and a waitingarea. Medical services provided includedantenatal care to pregnant women andsexual and reproductive health services.

Between 2 May and 31 December 2015, MSFteams aboard the three vessels rescued

20,129 people in the Mediterranean Sea,about a quarter of whom were women andchildren. Of the 123 boats in distress thatMSF teams assisted, 95 were inflatableand 28 were wooden. On 31 December2015, the last MSF SAR vessel still at sea,the Bourbon Argos, stopped its activitiesin order to redirect MSF resources towhere they are most needed in departurecountries, in transit locations and alongother well-worn routes into Europe,including the Eastern Mediterraneanroute, through the Aegean Sea…

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On 28 October 2015, 43 people, including20 children were reported dead after a boatcapsized near the Greek Island of Lesbos.That same day, 19 people went missing aftera boat sank off the island of Kalymnos in theDodecanese. Four people went missing off theisland of Samos and three people in an incidentoff the island of Agathonisi.

On 16 December 2015, a wooden boat carryingaround 85 people capsized off the northernshores of Lesbos. When the MSF-Greenpeace

assistance boats arrived at the scene, theteam quickly began rescuing as many peopleas possible, handing out floating devices tohelp those still in the cold water. Survivorswere transferred to vessels operated by othervolunteers. In all, 83 people were rescued andtransferred to the nearby towns of Molyvosand Petra. Many were in need of resuscitationor were treated for hypothermia by MSFteams at the arrival points, and three patientswere referred by MSF to a local hospital forhypothermia, among them a child. At least twopeople – an 80 year old man and a nine monthold child – drowned.

People who embark on the journey to Europe facemany dangers. These include the risk of drowningfollowing boat capsizes or during rescues,which are always very delicate operations27. Thecrossing from Libya to Italy takes an averageof 30 to 74 hours and the crossing from Turkeyto Greece takes 45 minutes to a few hours.Shipwrecks are common, especially if weatherconditions are rough. Vessels are mainly smallinflatable Zodiacs or old, wooden fishing boatsand are often unseaworthy and overcrowded.Migrants and refugees are frequently left aloneonboard with no experience of the sea, nonavigation equipment and meagre fuel. It is littlewonder the vessels often get in to trouble soonafter their departure.

“No one knew how to drive the boat, we

were all saying ‘we will die, we will die!’A lot of water entered the boat. We allmoved on one side and the boat almostturned over! We were all in shockand we were all crying. I was thinking‘it does not matter if I die’, but I wasworried about the two little girls” (onefour year old and one seven year old)

17 year old girl from Somalia, aboard the MSFsearch and rescue vessel Dignity I.

On 5 August 2015, after a wooden boat carryingbetween 600 and 700 people capsized close to theLibyan shore, the MSF search and rescue vesselDignity I was called to assist. Only 300 peopleare believed to have survived the shipwreck.Survivors explained with horror how the boatwas mainly filled with families and that most ofthe people missing were women and childrenwho did not know how to swim.

“It was a horrific sight, peopledesperately clinging to lifebelts, boatsand anything they could to fight for theirlives, amidst people drowning, and thosewho had already died.”  

MSF project coordinator on board the Dignity I,August 2015

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

On 29 October, MSF provided support to awoman and her three daughters after theirboat capsized near the island of Farmakonisi.The MSF Field coordinator in the Dodecaneseislands explains :“They were desperate; wehelped them change their wet clothes and gavethem blankets. The woman was brought to theHospital of Leros and we provided psychologicalsupport to the daughters. The husband arrivedwith a second trip of the boat bringing people

from Farmakonisi to Leros and they werereunited.” The following day, after a shipwreckoff the island of Kalymnos, our psychologistconducted sessions with 10 survivors, includinga 27 year old Iraqi man who had lost his disabledbrother, a 32 year old Syrian man who had losthis three children and a 35 year old Syrian manwho had lost his wife, son and daughter.

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

Medical teams on board search and rescuevessels have time and again witnessed theterrible, precarious and often life-threateningconditions experienced by people in transitcountries such as Libya and on board the flimsyvessels in which they make their sea journeys.With scant food, water and blankets on board,passengers, especially the most vulnerable,face dying of dehydration, hypothermia orexhaustion28. Of the 4,443 patients treated by theBourbon Argos medical team in 2015, aroundhalf were suffering from minor ailments and a

considerable number suffered from more seriousailments, including violent trauma (39 patients,or 1%), scabies (1236 patients, 28%), chemicalburns (69 patients, 2%), trauma (72 patients,4%), dehydration (10 patients) and more recentlyhypothermia (two patients in Bourbon Argos andsix patients in the Aegean SAR).

The impact of people’s experiences and traumaat home and during the journey on their mentalhealth is difficult to measure, but also requiresclose attention. MSF conducts individual andgroup sessions with people arriving in theislands, and also provides psychological first

A boat containing approximately 650 peopleis rescued in the Mediterranean Sea bythe Bourbon Argos.

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B. AGGRAVATED FACTORS FOR DISTRESSAT SEA - TARGETED VIOLENCE AT SEAAND ON SHORE

Left to fend for themselves on unseaworthyboats, refugees and migrants don’t only facethe dangers of the sea, but at times also faceattacks during the crossing.

In July 2015, our teams in Lesvos and Kos beganto be approached by refugees who wantedto share their troubling stories of violenceat sea involving unidentified masked groupseither robbing them or throwing their personalbelongings overboard. Some people recountedbigger boats approaching dinghies and trying topierce and sink them with long perches. Othersdescribed boats seemingly belonging to theGreek Coast Guard sailing by without comingto their rescue. Our teams continue to receivesuch reports from those arriving on the Greekislands.

‘We were attacked in between Turkeyand the island (Farmakonisi), by 3 menin uniforms on board of a large metallicgrey boat. I saw 3 male adults on board,wearing dark blue naval uniformswith a greek flag on the shoulder. Wegot closer to them, showed them ourchildren to get some support from them.I cannot forget what happened. Once we

got close to them they used the harpoonto brutally punch our boat in front. Theydid 2 holes and it was completely thepanic on our board. They wanted to killus. I don’t want it to happen again toother refugees. Before the attack […],the sea was quiet and we were not indanger. Our lives and lives of my ownnephew would not have been in danger ifthe men would not have attacked us.’

Syrian man, Kos, Greece

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

the hulls of inflatable boats. In some accounts,the boats were towed back to Turkish waters 29.

In November 2015, our medical teams in Lerostreated patients who had just survived an attackat sea :

“We left the Turkish coast with 45 people on board (…) After a while a big motorisedgrey boat approached us (…) It was armed with a heavy weapon and had a Greek flagon it (…) I saw three men (…) wearing dark blue uniforms with the Greek flag. Weshowed them that we had children on board and that we needed support (…) Onceclose (…) they took a long metallic stick with a hook and (…) hit the (…) [anterior buoy].The first two punches came fast and perforated the front of our boat . The waterquickly started to enter our boat. Children and women were shouting. We startedfrantically to use our hands to bail out the water from the boat. There was total panicon board. After a while (…)we saw another big metallic boat. This one was orange,

(…) [with] five men inside, wearing the same dark blue uniforms with clear blue flags.We shouted and asked for their help... we saw the men on board laughing loudly.(…)We watched this boat returning to the island, Farmakonisi. The people in my groupsay they are sure that it was the same boat that later brought us from the islandFarmakonisi to here, Leros. The panic on board is indescribable (…) We all saw deathcoming. We had children on board, how can somebody do that to children? We fledour country because our lives were in danger there. The first thing happening to usentering into Europe is men in uniform trying to kill us.‘’

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

MSF and Greenpeace conduct joint seaoperations to provide assistance to boatsin distress off the coast of Lesbos.

Refugees prior to embarkationon board the Bourbon Argos.

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MSF teams treated two children that survived theattack described above. One eight year old boycame to the MSF clinic with his father. He told ourdoctors “Since we have been in the water I feelvery sad. I don’t know why but I feel very sad”.Fighting back his tears, his father explained thathis son had difficulty sleeping since the attack,waking up with nightmares, as well as sufferingfrom bronchitis.

Another child, six years old, came to our clinicwith his mother. Having fled from the war inAfghanistan, she explained :“My son was completely in the water,there was water all in the boat after theattack. But I managed so that his headdidn’t enter the water until we reached

the island Farmakonisi. He was in myarms and I was holding him so tight. Iwas afraid. His whole body was black.His lips were completely blue. It was amiracle nobody died.‘’

MSF teams carrying out mental health activitieson shore report that patients who face incidentsof violence at sea have already been throughdistressing experiences related to war, violenceand persecution on land. Facing ill-treatmentor violence during this journey by boat serves toaggravate the psychosocial risk they are subjectto, and often leads to intense distress, andsymptoms of acute anxiety, hopelessness, fearand insecurity.

The involvement of the Greek Coast Guards inthese attacks has been denied publically by theGreek authorities, but no thorough investigationsare known to have taken place. Given Frontex’ssupport to the Greek Coast Guards, it has a

key role in following up on these claims withthe Greek authorities so as not to render theEuropean Union complicit of such potentialcrimes.

Abuses have also been reported on the Greekmilitary island of Farmakonisi by patients wetreated in Leros and other Dodecanese Islands.Out of 343 patients supported for traumaticevents by our medical and mental healthteams in Greece in 2015, 81 (24%) reported thatincidents had taken place on Farmakonisi.

“On the military island they made us kneel,waiting in the sun for many hours. You cansee that we are burnt from the sun. Theyhad tied our hands and were slapping uswithout any reason. Also, when we weresleeping they came inside the room andbeat us with iron sticks. They took mymobile battery and then they asked me for20 euros to get it back.”

31 year-old Syrian man, Leros, Greece

“We were on the military island. Asoldier was shouting in English ‘I don’tcare about the laws – For me the lawsdo not exist – Here there is only one law

– The army law.”40 year-old Iraqi man, Leros, Greece

“We were asked to switch off our mobilesand put them in a bag with our money.I put my wallet inside. I had 1200 eurosto continue my trip. When they returnedour stuff, my money was missing. Theyhad left only the Turkish Liras insidemy wallet. I don’t have money. I had leftsome money with my wife and childrento manage until the time I arrive to mydestination. A soldier asked me to standup and start running. I explained that Icouldn’t do that as I have a problem withmy leg. He kicked me on the same spotthat I had been injured. You can see thatmy leg is swollen.”

27 year-old Iraqi man, Leros, Greece

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

Our patients tell us they are aware ofthe risks involved in the dangerous seacrossing, but that they are ready to die.Those who have life jackets sometimeswrite names of relatives to be contactedin case they drown : “When I ask peoplewhy they risk their lives in this way, Iget the same answer every time : ‘thereis no alternative.’ These people knowthe dangers but they take the gambleanyway. They tell us that they wouldrather drown seeking safety and freedomthan stay in their homelands or in Libyawhere their lives are not worth living.”  

MSF Emergency Coordinator on board of the MY

Phoenix

Although proactive and large scale SARoperations are necessary to save lives indanger at sea, they are not the solution toforced migration by boat. They will never fullyprevent refugees and migrants from dying atsea, and they will not prevent attacks at sea.It is the lack of safe and legal alternatives toapply for asylum or migrate to Europe thatforces people to resort to smugglers and risktheir lives on such dangerous and uncertain

 journeys. Safe alternatives to the dangeroussea crossings exist, including land crossingsbetween Turkey and Greece, as well betweenTurkey and Bulgaria. But today, these safe andlegal alternatives continue to be dangerouslyoverlooked by member states of the EuropeanUnion who have instead invested their resourcesand efforts in blocking the flow of asylum

seekers and migrants and launching militaryoperations against the smuggling industry inLibya, while turning a blind eye to the violenceplaguing its own borders.

MSF and Greenpeace conduct joint seaoperations to provide assistance to boatsin distress off the coast of Lesbos.

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For those who have survived the sea journeyto Europe’s shores, new challenges lie aheadincluding finding a safe place to disembark,understanding the registration process andbeing able to find adequate shelter and essentialservices. MSF teams have seen many of thepeople rescued smile, raise their hands and kissthe ground when they finally set foot on Europeansoil. Unfortunately, for the majority, the obstaclecourse to safety is far from over and many newdangers await them in Europe.

GREECE

In 2015, Greece  became the first entry pointfor migrants and refugees attempting to reachEurope. As of 31 December 2015, 851,319peoplehad crossed the Mediterranean and arrived in

STEP 3 : ARRIVING IN GREECE AND ITALY -

INADEQUATE RECEPTION CONDITIONS FOR ASYLUM

SEEKERS IN GREECE AND ITALY

“I avoid drinking water…in that way I willnot to have to go to the toilet.”

Syrian Woman in Kos, Greece

Greece, mainly in the ports of Lesvos, Samos,Chios, Kos and Leros. More than 91% comefrom countries affected by war or generalisedviolence (mainly Syria30, but also Afghanistan,Iraq, and Somalia) and over a third are womenand children.

Despite deteriorating weather condition andmost likely due to the perception that Europeanborders are closing, October 2015 saw thelargest number of people arriving in Greece, with

an average of 8,700 people arriving every day inthe Greek islands in the week 15-21 October31.

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

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

The island of Lesvos, where close to 60% of allmigrants and refugees arriving in Greece land,only had a daily reception capacity of 1,480 peoplein October 201534. This was nowhere near enoughto provide shelter for the estimated 5,000 peoplewho arrived each day and spent up to severalsubsequent days on the island. As of October2015, Syrian families had to register in KaraTepe camp, where they usually spent the nightin very basic tents or Ikea pre-fabricated houses,before leaving the next day for the port of Mitilinito reach Athens by ferry. Single Syrian men andpeople from other nationalities had to register atMoria camp, the first Greek ‘hotspot’, where non-Syrians have to wait about three days for theirregistration, with little or no accommodation orassistance provided. As a result, whole familiesand groups were sleeping rough in the vicinity of

the registration camps, with very little protectionfrom the sun, cold and rain, under trees, orin small tents if they were able to buy one. Formonths, humanitarian organisations have beencalling on the Greek authorities to improve thereception conditions in Moria site and increasethe shelter capacity on the island.

A dramatic reception crisis

For years, Greece has been unable to offerdecent reception conditions to asylum seekers.Only two islands, Lesvos and Samos, havereception facilities in place, although eventhese remain insufficient. Faced, since May2015, with an increased flow of refugees andmigrants arriving on its shores and waitingto be registered, existing local capacity wasimmediately overwhelmed. Organising thereception of a population, registering the manyvulnerable groups arriving unannounced andonly transiting for a few days is a real challenge.But the lack of adequate and speedy responsefrom the authorities has allowed the situation tospiral out of control, and has led to unacceptableliving conditions for these already vulnerablepeople. A year into this crisis, despite numerousvisits by EU representatives including theEuropean Commissioner for Migration32, boththe reception infrastructure and the asylumsystem in Greece continue to fail to adapt to theneeds of the refugees and migrants.

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

Average # daily arrivals in Oct33 # Number of reception places

Lesvos : 4,400 700 official and 780 by humanitarian actors

Chios 900 110

Kos 800 0 official, 200 by MSF

Leros 400 0 official, 421 by humanitarian actors

Samos 800 250

DODECANESE ISLANDS

IDOMENI

LESBOS

ATHENS

MSF PROJECT LOCATION

RESCUE OPERATION

MIGRATION ROUTE

SAMOS

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“People arrive on the Greek islands afterhaving gone through a lot of hardship. Wehave seen children and adults still wet,who are forced to sleep outdoors. Thereare patients with diabetes and there is noprovision of medical screening or specialnutritional requirements. All theseconditions are especially harmful for therefugees’ health, besides the fact thatit is insulting for their dignity as humanbeings.”

MSF Medical Doctor, Dodecanese Islands, Greece

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

On the island Kos, where 200 to 500 peoplewere arriving every day in October 2015,there is no reception facility, as the localauthorities continue to oppose the creation ofany organised reception or transit facility onthe island. In the informal camp of CaptainElias, 500 to 700 people used to sleep on thefloor of a dilapidated old building that MSFrehabilitated with a capacity of maximum200 people. Under pressure from the localauthorities, this informal camp was closed andpeople were evicted on 10 September 2015.In September, MSF created shelter for 200people behind the police station.

“We have been here for five days. Lifehere is very expensive. Hotels as well.We cannot afford them. That’s why wehave to stay in the streets. But everyday in the streets costs us money. Everyday we have to chase the shadow. Fromthe shops and cafes they push us. (…)We do not want to stay here, we want toleave. But here every day the situationis getting worse […] We drink waterfrom the water points that are made forthe private yachts. When there is onerunning we try to take the opportunity…There is also one toilet that they openfor one hour per day.”

Syrian man with his wife and five children, Kos,Greece

On other islands where there are no officialreception centres, thousands of new arrivalshave had no other choice than to settle in publicparks, where they have little or no access to

water, shelter, toilets or medical care. Withvery little assistance provided, these vulnerablepeople have had no access to vulnerabilityand medical assessments or referrals forthose most at risk. In addition to these livingconditions, the Greek authorities graduallywithdrew all food provision in the Greek islandsduring the summer.

none of the people we talked to hadreceived any information on what wasgoing on, most waited around on thegravel field, too scared to leave to goand get water or food outside. The twoavailable toilets quickly filled up andbecame unusable.”

“Since only three police officers were incharge of registration on Tuesday, theprocess was extremely slow and somepeople in the crowd, forced to queueunder the sun all day long, startedgetting upset. The police, unable tokeep control of the situation they had

created, used tear gas to disperse themthat afternoon and at least one stungrenade in the evening. The situationinside the stadium quickly degenerated :roughly 2500 people were locked in allWednesday. People were fainting atan alarming rate and urgent referralsto the local hospital needed to beorganised. All the people I talked to werecompletely lost as to what was going onand why they were being treated thisway. Their main concern was to try andfind a way to find food and water withoutlosing their spot in the registrationqueue, while not drinking too muchsince there were no toilets. It was a veryshocking couple of days.” 

MSF Humanitarian Affairs Officer, Athens, Greece

During the event, our teams treated seven peoplecrushed by the crowd and 33 for heat exhaustionand loss of consciousness. We referred fourpatients to the local hospital and received atleast three reports of police violence.

A failure to provide swift accessto registration and information

The failings of the Greek authorities are notlimited to the lack of reception, but also includethe failure to provide swift and effective accessto registration procedures and informationregarding asylum procedures and basic services.

Indeed, the administrative registration processin Greece, which is carried out by the police, ismandatory, extremely heavy, constantly changingand involves, in some islands, 15 different steps.Throughout the summer, each Greek islandfollowed a different registration system.

The lack of swift access to registration; thecomplete absence of information provided bythe police and Frontex; as well as the lack ofadequate crowd control, have repeatedly led tochaotic situations  with tear gas and violenceused by the authorities. Humanitarian organi-sations have been forced to take on the state’sresponsibility of providing crucial informationto the refugees and migrants and in some in-stances even forced to handle crowd control.

“We were given a piece of paper bythe port police, but since then we havebeen waiting here and have heardnothing. Nobody tells us anything.There is no one responsible for givingus any information, and we don’t knowwhat to do. No authority, no police, noinformation, nothing.”  

26 year-old Syrian man with his wife and baby,Lesvos, Greece

In Kos, registration descended into chaos on 10-12 August 2015.

“On Monday 10 August, the localauthorities on Kos Island begansweeping operations to push the peopleaway from the town centre. Syrianfamilies were told to gather at an openair stadium and await registration there,instead of the police station. Over thecourse of the day, the numbers in thisopen-air stadium started to swell. As

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The health impact of the government’sfailure to provide access to receptionfacilities and other essential services

In Greece, the lack of swift registration andadequate reception conditions has put thehealth and safety of refugees and migrants atrisk. For months, our medical teams throughoutGreece have treated the health consequencesof the extremely precarious conditions refugeesand migrants are forced to endure for days36 before their identification and registration iscompleted.

Between June and November 2015, twothirds of the patients seeking care in MSFclinics in Greece suffered from respiratorytract infections, skin diseases and trauma –all linked to the dangerous and unhygienicconditions they were living in. Among women ofreproductive age that attended MSF clinics, 838(13%) were pregnant while 4,360 (14%) werechildren under five years old and 2,233 (7%) ofour patients had a chronic disease, includingdiabetes, cardiovascular disease, lung disease,cancer and chronic renal failure requiringdialysis. With no screening of people’s medicalvulnerabilities on arrival, the system, or ratherlack thereof, further endangers the lives ofrefugees and migrants.

“We have witnessed a lot of pregnantwomen and children queuing forseveral days in the mud, soaking wet inthe pouring rain without any protection,some of them only wearing a t-shirt.People can’t stand up anymore becausetheir feet are swollen after beingwet for several days. Without theintervention of our medical teams orvolunteers, police don’t allow refugeesto leave the queue to have access tohealth care. Our staff have to look forthe sick and injured in the queues tobe able to redirect them to the clinic.In addition, the registration process

keeps on being changed, with noinformation shared with the people andhumanitarian organisations. This iscompletely inhumane.”

MSF Project coordinator in Lesvos, Greece

The situation – already worrying over the summer– has only got worse with the rains setting inand winter approaching. MSF medical teamsin Greece saw a 160% increase of respiratorytract infections between July and October2015. Patients described how they had fallensick sleeping outside on the bare ground, withno protection from the rain and cold. BetweenOctober and December 2015, our medicalteams in Greece and Serbia treated 19 cases ofhypothermia, 12 of which were in Idomeni, at theGreek-FYROM border.

The lack of access to information and basicservices such as shelter, food and sanitationimpacts not only people’s physical health, butalso on their general well-being and mentalhealth. An MSF psychologist working with asylum

seekers and migrants in Greece explains :“Although arrival in Europe wouldnormally mean having finally escapedwar and violence, people’s situations arestill difficult due to the lack of a properreception system. This leaves themexposed to additional fear, insecurityand risks such as the non-fulfillment of

their basic needs and limited access tobasic medical care or legal information.People with previously identified mentalhealth difficulties are facing the risk of adeterioration of their health due to the lackof a timely identification of needs and theproper referral to medical or other care.” 

Failing to comply with EU standards of recep-tion, the Greek authorities have focused exclu-sively on police and registration procedures,neglecting to put in place an asylum receptionsystem and failing to respond to the urgent andessential needs of the refugees and migrants –be it for shelter, food or water and sanitation.These shortcomings, which are of particularconcern given the vulnerable condition of these

people, are not only morally and ethically un-acceptable, but also violate basic human rightsand EU and Greek legislation37. The treatmentof asylum seekers in Greece was qualified asinhumane and degrading treatment by the Eu-ropean Court of Human Rights in 2011, and atthe beginning of 2015, UNHCR called on EUmember states to suspend Dublin transfers ofasylum seekers to Greece.

A 7 months pregnant asylumseeker in Serbia

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MSF MEDICAL ACTIVITIES IN GREECE

Between 17 March and 27 December 2015,MSF teams provided just over 43 000 medicalconsultations to refugees and migrantsin Greece.

KOS

In December 2014, after a four month long emergency intervention on the island of Kos, MSF decidedto withdraw, as we came to the difficult conclusion that given the circumstances in which people wereleft stranded on the island, our medical impact was limited 38. MSF returned to the island in March 2015and has been providing primary health care as well as mental health support and information to peoplearriving; distributing Non-Food Items (NFIs) and working on sanitation facilities and shelter. At the timeof writing, there is still no state-organised reception on the island.

Between 17 March and 12 December 2015, MSF undertook 8,700 consultations, of which 37% werewomen and children; 158 individual mental health sessions and 509 group sessions with 4,242participants.

LESVOS

MSF began its activities in Lesvos in July 2015, providing medical and mental health care in the Moriaand Kara Tepe registration camps, as well as at the port of Mitilini. Teams also provide temporaryshelter and transport to and from the Mantamados transit point. In November 2015, MSF stepped upits presence and activities on the northern shore of the island where most of the boats arrive. Medicalteams aboard two ambulances stand ready to provide urgent medical care and refer patients as theyarrive on shore.

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

LEROS AND SMALL DODECANESE ISLANDS

In June 2015, MSF started visiting the islands of Leros, Simi, Tilos and Kalymnos and established apermanent presence on Leros in September, with teams working on shelter, water and sanitation,distributing NFIs and providing mental health support and primary health care services.

Between 15 June and 12 December 2015, MSF carried out 4676 consultations, of which 68% were womenand children; 69 individual mental health sessions and 268 group sessions with 1552 participants.

SAMOS

In October 2015, MSF put in place an ‘emergency call’ service, enabling MSF teams to be called whenboats arrived. Medical teams provide first aid to refugees and migrants disembarking and transportthem to the closest town on the island, Vathy.

Between 5 October and 1 November 2015 MSF carried out 645 consultations, of which a third were forchildren under the age of five.

ATHENS

MSF is also present in Athens, where MSF teams started mobile clinics in December 2015. As a resultof, new restrictions on movement imposed at borders, an increasing number of refugees and asylumseekers are staying in the capital.

In collaboration with the Greek organisations Babel and the Greek Council for Refugees, MSF teamsin Athens are also providing medical and psychological services as well as legal support to refugees,asylum seekers and undocumented migrants who have been victims of torture. In September 2015, theteam had 136 patients in the program. The most commonly referred types of torture are blunt and headtrauma, threats, and bad detention conditions. Most patients suffer from one or several mental issuesincluding anxiety, depression, psychosomatic symptoms or symptoms of psychosis. Forty percent ofpatients present symptoms of post-traumatic stress disorder (PTSD).

GREEK-FYROM BORDER

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

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

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

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ITALY

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

One example of the failure of Italian authoritiesto meet the reception needs of refugees andmigrants is the reception centre of PozzalloCPSA  in Sicily. Designated by the EU as oneof the ‘hotspots’, which aims to improveregistration and processing capacity in Italy, itofficially offers 300 places43. The real capacityof the centre, however, is 180 places.

In November 2015, MSF submitted a report tothe Italian Parliamentary Investigative Commis-sion on the Reception System, the Identificationand the Treatment of Migrants, highlighting theinadequate conditions of the centre and the lackof efforts made by local authorities to addressthe issues. As detailed in the report, the centre

is often overcrowded. Structural problems haveled to poor hygienic conditions and difficulties inproviding treatment for certain ailments such asscabies. The lack of space also means that it isnot possible to separate unaccompanied minorsfrom adults and women from men, and that thereis no designated space to identify vulnerable in-dividuals such as victims of torture, or traffickingand survivors of other forms of violence. Depend-ing on available places in first reception centres,people might spend a few days inside the centre,including vulnerable individuals such as pregnantwomen, families, unaccompanied children andpeople with psychological issues.

Inadequate reception conditions and accessto essential services

Even though Italy is better prepared forreceiving migrants, asylum seekers andrefugees than Greece, with a formal receptionsystem of 99,09641  places, assistance at theexternal borders and reception conditionsare still largely insufficient and ill-adapted  to the needs of those arriving. Disembarkationconditions at different landing spots in Italyare not homogenous, despite the release in2014 of the Contingency Plan for Health inthe context of Migration42, issued by the SicilyRegion. This is due to variations in the levels ofresources made available, and in the presence

and coordination of the different organisationsinvolved. In some harbours MSF has witnessedsecurity protocol and procedures that are tothe detriment of an appropriate humanitarianapproach to disembarking refugees.

Capacity at first reception level (Centre of FirstAid and Assistance or CPSA) is problematicdue to the lack of adequate strategic planningnationally, coupled with poor management ofresources. This has resulted in centres facingovercrowding and offering limited access tolegal advice and healthcare.

MSF PROJECT LOCATION

SEARCH AND RESCUE BOAT

RESCUE OPERATION

MIGRATION ROUTE

BOURBON

AROGS

SICILY

ROME

MY PHOENIX

DIGNITY I

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“Today, 18 corpses arrived in Pozzallo.More corpses. Is there anybodystill thinking that people take thedecision lightly to cross half of theworld risking their lives to reach thewonderful Europe? (…) On Friday, inAugusta, we received a child with acentral venous line for chemotherapy.Last week a paraplegic Eritreangirl landed in Pozzallo, after havingcrossed the desert in a wheelchair.Some weeks ago a teacher from IvoryCoast told me he worked in Libya fortwo years and wassuddenly forcedto escape because of ‘black-people

hunting’.” MSF Project Coordinator in Pozzallo, Sicily, Italy.

An additional problem with regards to PozzaloCPSA relates to the identification and regis-tration procedures. These procedures shouldnormally take place only after legal informa-tion is provided to asylum seekers arriving inthe centres. As highlighted in the report to theParliamentary Commission, MSF is concernedthat identification procedures are carried outvery quickly, while medical and humanitarianresponses are still taking place, curtailing thenecessary space and time for the individualsto take some rest and receive all the necessarylegal information. In September and October,MSF’s teams in Pozzallo witnessed about 100cases in which rapid identification procedureswere immediately followed by expulsion notic-es and requests to leave the CPSA. Such casesincluded several women, one of them preg-nant, two minors and several people in need

of or undergoing medical treatment. After thiswas raised with relevant authorities, theserapid procedures and expulsions, which riskedcompromising the adequate assessment ofpeople’s asylum claims, were stopped.

In December 2015, MSF announced the end ofits activities in the Pozzallo CPSA, as conditionswere no longer suitable for the organization towork there.

The inadequacy of the first level receptioncapacity is linked to the emergency context inwhich the general reception system structurewas scaled up in 2014, as numbers of asylumseekers soared. Indeed, 70,918 asylum seekersare currently hosted in the temporary CAScentres, whereas only 21,814 are hosted insecondary level SPRAR (Protection System forRefugees and Asylum Seekers) structures.)dedicated to the reception and integrationof refugees. The widespread developmentof CAS44  centres does not reflect a plannedand structured response and remains,unfortunately, emergency focused.

The absence of a consolidated receptionstrategy has led to the current lack of adequatereception structures (many are located in

remote areas and lack basic facilities), as wellas qualified and experienced personnel able torespond to the multiple needs of the asylumseekers. Essential services that should beprovided in CAS structures (including primaryand secondary health care, mental health care,and legal and administrative support) are under-resourced, under-staffed and lack qualifiedcultural mediators and interpreters. Additionally,administrative support for the completion oflegal and administrative formalities is providedby local and national institutions whose humanresource capacity remains limited, reducingtheir capacity to respond to the assistance needsof a growing asylum seeker population.

The reluctance of refugees to remain in Italy in thecurrent reception system leads many of them, inparticular those of Eritrean origin45, to continuetheir journey toward northern European countries.They often arrive from landing ports in Italy (orafter staying a short time in CPSA structures)and remain in the territory for a limited periodwhile they regroup46  in order to reach their finaldestination. MSF has approached this populationin transit in two informal spots in Rome, atTiburtina train station and at the Baobab centre,providing them with practical assistance suchas general orientation, information about healthcare rights, legal information and transportation,provision of intercultural mediation, emotionalsupport, psychological first aid and family linkingservices47.

A worrying lack of access to healthcare