EDITORIAL BOARD

BIFFL, Gudrun

CAMPOSTRINI, Stefano

CARBALLO, Manuel

COSTANZO, Gianfranco

DECLICH, Silvia

DENTE, Maria Grazia

GEORGE, Francisco

GUERRA, Ranieri

HANNICH, Hans-Joachim

KONRAD, Helga

KRASNIK, Allan

LINOS, Athena

MCKEE, Martin

MOSCA, Davide

NOORI, Teymur

OROSZ, Éva

PADILLA, Beatriz

PEREIRA MIGUEL, José

Manuel Domingos

REZZA, Gianni

SALMAN, Ramazan

SIEM, Harald

Coordinators

ÖSTLIN, Piroska

SEVERONI, Santino

SZILÁRD, István

WHO Regional Office for Europe

BARTOVIC, Jozef

University of Pécs

BARÁTH, Árpád

CSÉBFALVI, György

EMŐDY, Levente

GOLESORKHI, Kia

KATZ, Zoltán

MAREK, Erika

Role of Civil Society in Refugee and

Migrant Health

Editorial by Piroska ÖstlinWHO Regional Director for Europe a.i

Nongovernmental organizations (NGOs) and civil society arevalued partners of the WHO Regional Office for Europe and playa crucial role in providing health care for refugees and migrants.I am delighted that this edition of the Migration and HealthNewsletter focuses on this theme, giving useful insights intohow NGOs and civil society contribute to delivering healthservices to refugees and migrants, as well as being strongadvocates of their right to health.

First, their contribution is perhaps most recognized when itcomes to covering a variety of health services, includingoutpatient consultations, vaccinations, mental healthconsultations as well as briefing refugees and migrants on theirrights and promoting health literacy. For example, in 2018alone, Médecins Sans Frontières/Doctors of the World providedover 26 000 outpatient consultations and almost 5000 routinevaccinations in Greece, as well as over 2700 mental healthconsultations in Italy. Their work extends beyond the borders ofcountries encountering large arrivals of refugees and migrants,to include support in countries with more traditional migrationflows, assisting foreign students and labour migrants forexample.

Secondly, NGOs do not just delivering care, they also play acritical part in developing societies, improving communities andpromoting the participation of refugees and migrants in servicedesign and service provision. With the help of NGOs, care canbe provided to a greater number of refugees and migrants inthe WHO European Region. It can also be adapted to meet theirspecific needs. NGOs and civil society have worked towardsimproving the cultural, religious, linguistic and gendersensitivity of health services, some of them specializing in thecare for victims of torture and trafficking.

Thirdly, NGOs make an essential contribution in advocating forthe rights of refugees and migrants in the Region, drawing theattention of both the public and policy-makers to pressingissues. For example, during our third annual Summer School inÇeşme, Turkey, this year, an NGO representative drewparticipants' attention to the fact that access to health-care

December 2019

Content

EDITORIAL 1

OVERVIEW 3Rehabilitation of torture survivor refugees in Hungary: the Cordelia Foundation

NEWS 5

EVENTS 6

OPINION 7Introduction to the humanitarian work of Doctors of the World –Greece: milestones, achievements, good practices and the challenges 7

Towards an integrative multisectoral approach in provision of mental health and psychosocial support services 9

RECOMMENDED READING 11

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services is hindered in practice by significant shortages ofresources as well as by the lack of adequately trainedcultural mediators.

NGOs and civil society through their contributions andimpact are important stakeholders in delivering oncommitments such as the Global Compact for Safe, Orderlyand Regular Migration and to our daily work, collaboratingclosely with the WHO Regional Office's Migration andHealth programme.

Finally, I would like to draw your attention to thepublication of the book Health Diplomacy: spotlight onrefugees and migrants, launched on 17 September 2019during the 69th session of the WHO Regional Committeefor Europe. This book showcases good practices by whichgovernments, non-state actors and internationalorganizations and NGOs attempt to address the complexityof migration, by strengthening health systemresponsiveness to refugee and migrant health matters, andby coordinating and developing foreign policy solutions toimprove health at the global, regional, country and locallevels.

Preparing this issue of the newsletter gave us freshperspectives on the breadth and scope of NGO activities.Civil society works to promote social or political changefrom local to global levels. I would like to take thisopportunity to thank them for their invaluable work andencourage you to read on to find out more.

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OVERVIEW

Rehabilitation of torture survivor refugees in Hungary: the Cordelia Foundation

Lilla Hárdi

Cordelia Foundation for the Rehabilitation of Torture Victims

The Cordelia Foundation for the Rehabilitation of TortureVictims was established in 1996 as the only Hungarian civilmember of the global network of the InternationalRehabilitation Council for Torture Victims (IRCT).The Foundation is engaged in activities for public benefitwithin health care. Its activities are financed by grants andfunds, with the main donors being the European Unionand the United Nations's Office of the United Nations HighCommissioner for Human Rights. The Foundation'spsychiatrists, psychologists, specially qualified nonverbaltherapists, intercultural mediators and interpreters offer aset of complex services for the multiple problems of themulticultural target group (1).The therapeutic model of Cordelia Foundation can becalled a stay-and-go model (2).The go model was created through weekly visits to severalrefugee shelters, detention centres and sometimes prisonswhere those needing support were located. The therapistsentered their temporary housing and offered theirculturally special, symbolic (and temporary) home tocreate a therapeutic space.Individual therapies follow the phase-based therapeuticprinciples of Herman (3): building trust and safety at first,then exploring the traumatic details, loss and mourning,and finally supporting reintegration and reconnection. Asthese sessions regularly need the participation of a trainedinterpreter, the classical dual therapeutic situation isbroadened for a triangular situation.Group therapies and individual therapies are carried outon a verbal as well as a nonverbal level. Nonverbaltherapies use the tools of art, moving, music andrelaxation to prepare individuals who cannot immediatelyopen up for verbal therapy. It also contributes to buildingtrust for therapy.Torture is a human-generated trauma, with humans as theperpetrators and as the survivors. It is evident that duringsituations of torture, basic trust gets lost and it takes timeto build trust up again.

Vicarious traumatization is a key issue that must be dealtwith as those who have been engaged with in therapy ofextremely traumatized patients can easily be traumatizedthemselves. Everybody in the therapeutic team has to dealwith such transference, and countertransferencemechanisms are needed to protect the therapists and theinterpreters. For this reason, the Cordelia Foundationintroduced supervision sessions from the first year of itsactivity.The stay model was set up later when the Foundation wasable to set up local rehabilitation centres. There are threeplaces in the country where clients can make contact andcome for an appointment. This approach is similar to theHungarian general health-care model where patients areoffered psychoeducation in addition to therapy preparingthem for integration into the host society.Recently, with the change of the political discoursetowards asylum seekers and with the set-up of the transitzones, the Foundation does not have access to individualswhen they enter the country. It has only one, maximumtwo, opportunities to meet them so it has had to use anadaptation of the single session therapy model (2). Thesechanges have also resulted in a decrease in the numberbeing treated; currently this is 400–500 compared with600–800 annually before the changes in national policies.The Foundation regularly provides training sessions andregular individual and group supervision for professionalsin charge of traumatized patients. Some training is offeredon an international level.As part of the IRCT, the Foundation writes medical–legalreports based on the Istanbul Protocol for clients tosupport them in their asylum process. The Foundationcollaborates with national and international civilorganizations, sometimes with governmental bodies, todecrease the impact of torture of on both the individualsand their family members.

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Prevention of torture is an integral element of the activity ofmany of the member organizations of the IRCT. As such, theCordelia Foundation works with other IRCT members for theeradication on a global level of torture and other cruel,inhuman and degrading treatment in order to create abetter, more humane world.

References1. Hárdi L, Kroó A. The trauma of torture and the rehabilitation of torture survivors. Z Psychol. 2011;219(3):133–142. doi: http://dx.doi.org/10.1027/2151-2604/a000060.2. Hárdi L, Kroó A. Psychotherapy and psychosocial care of torture survivor refugees in Hungary: "a never-ending journey". Torture. 2011;21(2):84–97. PMID: 2171595.3. Herman JL. Trauma and recovery: the aftermath of violence from domestic abuse to political terror. New York: Basic Books; 1997.4. Talmon, M. Single-session therapy: maximising the effect of the first (and often only) therapeutic encounter. San Francisco (CA): Jossey-Bass; 1990.

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NEWS

Consensus conference for establishing a European level migration health database7-8 October 2019https://www.mighealth-unipecs.hu/

The conference entitled "Migration-related public health challenges and needed responses: defining conditionsfor establishing a European level migration health database – a consensus conference" was held at the Universityof Pécs, 7–8 October 2019 and jointly organized by the WHO Collaborating Centre at the University of Pécs andthe Migration and Health programme of the WHO Regional Office for Europe. Policy-makers, academics andpractitioners met to discuss the opportunities and challenges in setting up a European migration database. Asone of the key prerequisites for health and public health systems to become sensitive to needs is the availabilityof meaningful data, the Conference focused on how to collect and share data on the health of refugees andmigrants in the WHO European Region. A European migration health database could be an essential tool forevidence-informed planning and the development of public health systems responsive to the needs of refugeesand migrants.The Conference examined both the technical and the political aspects of the establishment of a Europeanmigration health database. The plenary sessions discussed existing initiatives, lessons learned as well as thepublic health significance of migrant health data. Specific topics and questions were raised during smaller,interactive workshops: data sources, data protection and legal aspects, digital technology and data collection,human resource capacity and training, best practices and country experiences.The Conference brought together leading experts in migrant health and concluded with an outcome documentthat summarized the basic principles for a coherent and consistent European migrant health database. This willnow be utilized to inform developments of coherent approach to data collection in the WHO European Region.The next issue of the Newsletter will cover the conference in detail.

HEN report on the availability and integration of refugee and migrant health data in health information systems in the WHO European Region

The latest HEN Report (HEN 66), which examined the extent to which refugee and migrant health data are beingincluded in health information systems, was launched at the Consensus Conference. The Report provides abaseline analysis on what refugee and migrant health data are currently available in the WHO European Region.Some data are collected in 25 of the 53 Member States, but the availability, data types and methods of collectionvaried across Member States. Predominant data sources are medical records, disease-specific records andnotification data. Overall, data integration was limited and untapped potentials exist in data linkage as well as inthe use of health monitoring surveys. The HEN Report recommended harmonizing definitions of migrant groups,coordinating and governing data collection, monitoring health information systems, collaborating and exchangingexperiences across countries, utilizing data linkage and expanding health surveillance, as well as strengtheninghealth information systems for the general population.

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EVENTS

12th European Public Health Conference: Building Bridges for Solidarity and Public Health20–23 November 2019, Marseille, France https://ephconference.eu/

WHO Global Vaccine Safety Summit2–3 December 2019, Geneva, Switzerlandhttps://www.who.int/news-room/events/detail/2019/12/02/default-calendar/global-vaccine-safety-summit

WHO Global Meeting to Accelerate Progress on SDG target 3.4 on NCDs and Mental Health9–12 December 2019, Muscat, Omanhttps://www.who.int/news-room/events/detail/2019/12/09/default-calendar/ncds2019

Winter School on Health Equity: The Quest for Health Equity in the Mediterranean Context – Focusing on Migrants and on the Poor16–20 December 2019, Rome, Italyhttps://www.inmp.it/ita/Winter-School-Health-Equity-2019/Winter-School-In-Rome-2019-Announcement

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Doctors of the World/Médecins du Monde (MDM) wasestablished in Greece in 1990 and since then has beenactive in the field of migration, rights and health, with acommitment to promoting activism for a universal right tohealth and equitable access to health care for all. Theguiding principle underlying MDM is that every human-being has the right to humanitarian assistance, irrespectiveof ethnic origin, religion, ideology or political belief. MDMobjects to social exclusion and the marginalization ofirregular migrants, poor and uninsured individuals, thehomeless and other vulnerable people with limited or noaccess to state health services (1).Since 2015, when hundreds of thousands of refugees andmigrants started to arrive in Greece from Turkey, MDM–Greece has responded to the peoples' health needs,organizing community-based interventions not onlythrough its open polyclinics in the cities but also in morethan 32 sites in remote areas in Greece (2). MDM–Greececommitted to cover gaps in the national health system andprovided access to qualitative primary health care, sexualand reproductive health and psychosocial support servicesto more than 350 000 individuals between 2015 and 2019.It also designed and conducted several health promotionactivities and collaborated with other health NGOs, theMinistry of Health and United Nations agencies duringmultiple immunization campaigns targeting the refugeesand migrants residing in the country (3). Currently, in theaftermath of EU–Turkey Common Statement, more than22 500 asylum seekers are struggling to survive ininhumane conditions in overcrowded reception facilities;for example, in the "hotspot" of Moria on Lesbos, childrenmake up approximately 40% of the population whilewomen make up 20%, all without any medical screening.The health risks are increasing enormously while the

inadequate living conditions have a heavy impact on thealready deteriorated health of the people (4,5). The factsspeak for themselves: 85 000 refugees and migrants in acountry with approximate accommodation capacity of lessthan 70 000; 4030 unaccompanied children, with 1200exposed to severe risks and rooflessness; 67 000 pendingasylum applications; 6500 migrants in detention withlimited medical care; and the vast majority of beneficiariesof international protection in hidden homelessnessbecause the national welfare system is not adequatelyequipped to support them (6–10).The national project PHILOS (Emergency Health Responseto Refugee Crisis) was been implemented by the GreekGovernment during this period and was expected togradually provide enough resources to cover all medicaland psychosocial needs of the refugee and migrantpopulation countrywide. It was also intended to supportasylum procedures by facilitating vulnerability screening inreception and identification centres. Almost three yearssince the beginning of PHILOS, the Greek authorities arestill struggle to effectively implement the project, withvery poor results in terms of proper health coverage (11).The further deterioration of health of refugees andmigrants in Greece might be seen as supporting the coreconcept of Hart's inverse care law: the availability ofqualitative medical care tends to vary inversely with theneeds of the population served (12). Greece is in need ofan immediate action plan in order to ensure the minimumstandards for refugee and migrant health. The role of thehealth NGOs is crucial at this point, and the only feasiblesolution is a collaboratively and multisectoral approachbetween the Greek State, the refugee and migrantcommunities and the civil society actors to ensure theappropriate delivery of dignified health-care services.

OPINION I

This article represents the opinion of the author(s) and publications and does not necessarily represent the views of WHO, theUniversity of Pécs or the Editorial Board of this newsletter.

Introduction to the humanitarian work of Doctors of the World – Greece:

milestones, achievements, good practices and the challenges

Anastasios Yfantis

Operations Director, Doctors of the World – Greece

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References1. Annual report 2018. Athens: Doctors of the World – Greece; 2019 (https://mdmgreece.gr/app/uploads/2019/06/ENG-Annual-Report19-Dig.pdfaccessed 5 November 2019).2. Falling through the cracks: the failure of universal healthcare in Europe 2017. Paris: Médecins du Monde; 2019 (Observatory Report 2017; https://www.medecinsdumonde.org/en/actualites/publications/2017/11/08/falling-through-cracks-failure-universal-healthcare-coverage-europeaccessed 5 November 2019).3. Vaccination of refugees/migrants in accommodation centres. Athens: National School of Public Health; 2017 (in Greek; https://government.gov.gr/wp-content/uploads/2017/02/Ekthesi-emvoliasmos-prosfygon-2017-02.pdf accessed 5 November 2019).4. Greece sea arrivals dashboard, August 2019 Geneva: United Nations High Commissioner for Refugees; 2019 (https://data2.unhcr.org/en/documents/details/71287, accessed 5 November 2019).5. Structural failure: why Greece’s reception system failed to provide sustainable solutions. Chios: Refugee Support Aegean; 2019 (RSA and Pro AsylReport June 2019; https://rsaegean.org/wp-content/uploads/2019/06/201906-STRUCTURAL-FAILURE-Why-Greece%E2%80%99s-reception-system-failed-f.pdf accessed 5 November 2019).6. Place of detention: pre-removal detention centres [website]. Athens: Greek Council for Refugees; 2019 (https://www.asylumineurope.org/reports/country/greece/detention-asylum-seekers/detention-conditions/place-detention accessed 5 November 2019).7. Mediterranean situation, Greece October 2019. Geneva: United Nations High Commissioner for Refugees; 2019 (https://data2.unhcr.org/en/situations/mediterranean/location/5179 accessed 5 November 2019).8.Situation update: unaccompanied children in Greece, September 2019. Athens: National Centre for Social Solidarity; 2019 (https://data2.unhcr.org/en/documents/download/71629 accessed 5 November 2019).9. A home for refugees: the need for housing throughout asylum procedures and beyond. Brussels: European Federation of National Organisationsworking with the Homeless; 2019 (https://www.feantsa.org/download/feantsa-joint-declaration-012019-31217046609951423028.pdf accessed 5 November 2019).10. Asylum Service statistical data [website]. Athens: Greek Asylum Service; 2019 (http://asylo.gov.gr/en/wp-content/uploads/2019/10/Greek_Asylum_Service_data_September_2019_en.pdf accessed 5 November 2019).11. PHILOS: emergency health response to refugee crisis [website]. Athens: PHILOS; 2017 (https://philosgreece.eu/en/home/about accessed 5 November 2019).12.Hart JT. The Inverse care law.Lancet. 1971;1(7696):405–412. doi: https://doi.org/10.1016/S0140-6736(71)92410-X.

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Mental health is one of the leading public health issuesand one of the main causes of disability globally (1). It isestimated that 35–50% of people with serious mentalhealth difficulties in developed countries do not receivetreatment, with up to 85% in developing countries (2).Refugees, migrants and asylum seekers are a particularlyvulnerable grouping because migration can bringnumerous mental health challenges: difficult livingconditions and traumatic events in the country of origin,the process of leaving the country, a potentially dangerousjourney and then the challenges of adapting and starting anew life.Receiving countries often face the challenge of addressingthe needs of the refugee and migrant community,particularly in regards to mental health. For example, since2015 there have been between 3500 and 125 000refugees and migrants in Serbia at various times; mentalhealth assessment data show that 70–85% of thesescreened positively for symptoms of depression, anxiety,current distress and post-traumatic stress (3). Based onthese data, Serbia needs to address the mental healthneeds and provide assessment, potential treatment andfollow up for approximately 3000–10 000 refugees andmigrants at any given point in time. In addition, refugeesand migrants may need different types of supportdepending on their duration of stay: from emergencyresponse to a long-term continuous mental health care.The sudden influx of psychologically vulnerable people hasput pressure on the existing health-care system in Serbia,as the number in need greatly surpassed the capacities of

institutions. In these circumstances, NGOs have playedimportant role, not only in the immediate response butalso in securing durable solutions for mental health carefor refugees and migrants. Specialized NGOs have beenable to provide highly skilled professionals (psychologists,psychiatrists) to work directly in the field and local NGOshave managed to engage communities to providepsychosocial support and humanitarian assistance.International NGOs have provided knowledge andexperience from others who have dealt with similarsituations. Furthermore, NGOs can fill the gaps and add tothe capacities of health-care systems that are adjusting torapid changes such as increased numbers of people,cultural differences and language barriers. Finally, NGOswith specific knowledge and experience can engage intransfer of knowledge through formal training and directcooperation, thus having long-term positive impacts onmental health professionals' capacity-building within apublic health-care system.NGOs play a critical role in emergency reponses but alsoact as an important resource during the transition fromemergency to long-term health-care solutions provided bya government. Consequently, it is of utmost importancethat state institutions work together with NGOs toestablish functional referral mechanisms and supportmechanisms to ensure a smooth transition. Equally, NGOsmust take responsibility for developing and executing exitstrategies that provide government institutions withsufficient resources and capacities to tackle the mentalhealth challenges of refugee and migrant population.

OPINION II

This article represents the opinion of the author(s) and publications and does not necessarily represent the views of WHO, theUniversity of Pécs or the Editorial Board of this newsletter.

Towards an integrative multisectoral approach in provision of mental health and

psychosocial support servicesJovana Bjekić and Maša Vukčević Marković

Institute for Psychology, University of Belgrade and Psychosocial Innovation Networ

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References1. Vos T, Barber RM, Bell B, Betrozzi-Villa A, Biryukov S, Bolliger I et al. Global regional and national incidence, prevalence and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries 1990–2013: a systematic analysis for the Global Burden of Disease study. Lancet. 2015;386(9995):743–800. doi: 10.1016/S0140-6736(15)60692-4.2. Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP et al. Prevalence, severity and unmet need for treatment of mental disorders in World Health Organization World Mental Health Surveys. JAMA. 2004;291(21):2581–2590. doi: 10.1001/jama.291.21.2581.3. Vukčević Marković M, Stanković I, Bjekić J. Psychological wellbeing of refugees in Serbia. Belgrade: Psychosocial Innovation Network; 2018 (https://psychosocialinnovation.net/wp-content/uploads/2017/09/Psychological-wellbeing-of-refugees-in-Serbia.pdf accessed 5 November 2019).

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RECOMMENDED READING

Better health for Europe: more equitable and sustainableWHO Regional Office for Europe, 2019https://apps.who.int/iris/bitstream/handle/10665/327427/9789289054225-eng.pdf?sequence=1&isAllowed=y

Critical reflections, challenges and solutions for migrant and refugee health: 2nd M8 Alliance Expert MeetingNefti-Eboni Bempong, Danny Sheath, Joachim Seybold, Antoine Flahault, Anneliese Depoux, Luciano Saso, 2019https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6423837/pdf/40985_2019_Article_113.pdf

Health diplomacy: spotlight on refugees and migrantsWHO Regional Office for Europe, 2019https://apps.who.int/iris/bitstream/handle/10665/326918/9789289054331-eng.pdf?sequence=1&isAllowed=y

Migration Health Annual Report 2018International Organization for Migration, 2019http://publications.iom.int/system/files/pdf/mhd_ar_2018.pdf

Psychotherapeutic and psychosocial care of torture victims in HungaryLilla Hárdi, 2003https://cordelia.hu/documents/Paper_Linz_2003.pdf

Supporting access to health care for refugees and migrants in European countries under particular migratory pressureAntonio Chiarenza, Marie Dauvrin, Valentina Chiesa, Sonia Baatout, Hans Verrept, 2019https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4353-1

Universal Health Coverage "leave no migrant behind"International Organization for Migration, 2019https://www.iom.int/sites/default/files/our_work/DMM/Migration-Health/mhd_infosheet_uhc_14.08.2019_web.pdf

What is the evidence on availability and integration of refugee and migrant health data in health information systems in the WHO European Region? Kayvan Bozorgmehr, Louise Biddle, Sven Rohleder, Rosa Jahn, 2019https://apps.who.int/iris/bitstream/handle/10665/328634/9789289054423-eng.pdf

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Contact us

Migration and Health ProgrammeWHO Regional Office for EuropeMarmorvej 51DK-2100 Copenhagen ØDenmarkEmail: EUPHAME@who.int

University of Pécs Medical School

Chair of Migration Health

Szigeti St. 12H-7624 Pécs, HungaryEmail: mighealth-unipecs@aok.pte.hu

© World Health Organization 2019

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