Greece: Refugees with Disabilities Overlooked, Underserved

Identifying People With Disabilities
The Greek Reception and Identification Service (RIS) is required to provide for the reception of third-country nationals entering the islands under conditions that guarantee human rights and dignity in accordance with international standards. The service is responsible for referring asylum seekers to social services and providing psychosocial support and information on the rights of migrants and asylum seekers. The RIS, supported by EU agencies such as Frontex and the European Asylum Support Office (EASO), as well as by the UNHCR, is also responsible for identifying and registering people who belong to “vulnerable” groups upon their arrival, which should include people with disabilities, including mental health conditions.

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A number of aid organizations told Human Rights Watch, however, that the registration process fails to systematically identify people with disabilities. A medical professional working for Médecins Sans Frontières (MSF) in Greece said: “There is a lack of resources, time, and expertise dedicated to the identification of vulnerable people. During the registration, if you don’t say it yourself, no one will ask you. If it is a disability that is not obvious, visible, even if a refugee reports it – it won’t be registered.”

A large-scale exercise to pre-register asylum seekers on mainland Greece by the Greek Asylum Service, with the assistance of the UNHCR and the European Asylum Support Office, in June and July found that only one percent of the over 27,000 people had a disability – which the UNHCR officials acknowledged to Human Rights Watch is an underestimate. The horrific violence in Syria and Afghanistan, which accounts for 47 and 24 percent of refugees in Greece, respectively, has caused physical disabilities and mental health conditions, in addition to the normal expectation of 15 percent.

Under Greek law, people such as pregnant women, children, victims of torture, and people with disabilities are considered “vulnerable” or at-risk, requiring access to special protection. This includes being exempted from the accelerated border process under the EU-Turkey deal, which is intended to send most asylum seekers back to Turkey. Furthermore, they should be given priority in the regular Greek asylum system and issued an asylum card while their case is being considered to allow them to move freely within Greek territory, including to the mainland, where they could have easier access to services.

However, in early December, the EU suggested measures that aimed to increase the number of returns to Turkey, including abolishing the exemption of “vulnerable” people from admissibility assessment.

On January 6, at a media briefing in Geneva, the UNHCR said that the slow registration and identification of “vulnerable” individuals has delayed transfers of asylum seekers from the islands to the Greek mainland before the onset of freezing temperatures.

In the fall of 2016, the UNHCR adopted a policy to provide 20 percent of its housing for asylum seekers on track for relocation within the EU in private apartments and hotels to “vulnerable” people. According to the UNHCR representative in Greece, as of December, 30 percent of this housing had been provided to “vulnerable” refugees. As many people with disabilities remain unidentified, according to aid organizations, they cannot benefit from this housing and continue instead to live in deplorable conditions in camps.

Yasami Habibi and her husband, Ali, from Afghanistan, arrived in Greece in March 2016 and were living in the Elliniko camp in Athens at the time of the interview. She said they had tried to register their 6-year-old son, who cannot speak and has difficulty walking, to no avail. Their son had not received any services, including much-needed medical care and rehabilitation services. With his two siblings, he sleeps on thin blankets inside one of the hundreds of tents that fill a baseball stadium in Elliniko camp.

Lack of identification particularly affects people with invisible disabilities, such as intellectual or psychosocial disabilities, but even some people with visible disabilities had difficulties registering. Ahmed and Fatima, an Iraqi couple in their late twenties, both have physical disabilities that make it very difficult for them to stand or walk. They said they were not allowed to register their disabilities because they did not have a medical certificate for proof. “When we went to register [on Samos Island] they asked us for proof that we have disabilities even though they can see we do,” said Fatima, who now uses a wheelchair.

A Norwegian Refugee Council representative said: “One of the problems is that inexperienced humanitarian staff are not fully trained in identifying disability. I was present when one unaccompanied child asked if he should be registered as disabled because he had severe burn injuries that affected his movement, and the person doing registration had not considered this as a disability and said, ‘He is not in wheelchair, he is not disabled.’” The representative said the boy said he had received painkillers from medical staff, but no other medication.

Mental Health and Psychosocial Support
Human Rights Watch found a lack of access to adequate and appropriate mental health care across the camps in Greece. Nearly all refugees and asylum seekers interviewed reported having headaches, losing sleep and appetite, and feeling depressed. Children had regressed to bed-wetting.

Only three of 20 people interviewed who reported being in urgent need of psychosocial support could get it.

The conditions in the camp and uncertainty about their future are key factors in the high numbers of people in need of mental health services. “What is worrying is that the needs are increasing every day,” a representative of Médecins Sans Frontières (MSF) in Greece said. “The main daily stressors of the individuals that we meet are the lack of certainty over the future, the access to asylum procedures, which is stalled, the living conditions. Concretely if there are no improvements, the needs will be even bigger.”

Eleni Perraki, a psychologist with the humanitarian organization Doctors of the World (MdM), working in Lagkadikia camp in the Thessaloniki region, said: “We see many people with post-traumatic stress disorder, people who are traumatized, stressed […] Some mental health conditions are the result of nothing else but daily life in the camp.”

Amer Omar, a psychologist with the humanitarian organization WAHA, Women and Health Alliance, has been working at Souda camp on Chios since March 2016. He said he thought nearly all of the 1,150 people there needed psychological support and mental health care: “Because life is very hard here... They have been in the camp for more than eight months – suffering the cold in winter, the heat in summer. They have their problems already from back home and journey – we have had several situations of nervous breakdowns.”

On several occasions, Human Rights Watch witnessed children, women, and men crying uncontrollably, or appearing agitated or distressed. Some said they had suicidal thoughts. A father of an 8-year-old boy with kidney disease said: “We are stuck in a place worse than Afghanistan. With the conditions like this, they push you to go back to Afghanistan. I would go, but I can’t because of security issues. Maybe at the end I will take my family and die in the sea in the same way as we came here.”

In Athens, “Hadad” a 16-year-old boy, and his 55-year-old mother “Afia,” from Afghanistan have been living in Schisto camp since March 2016. Hadad said: “We live trapped here. Like inside a prison. We cannot move, no one is saying what will happen to us.” Afia said that her son had disappeared for six days and was found by the police and the UNHCR in the nearby forest. “He has so much anger,” she said. “Sometimes he starts beating himself against the wall, causing himself injuries.”

Afia said that the only help her son received was medicine “that makes him sleep a lot.” She said that he had not been able to see a psychologist and that the situation was too much for her to bear: “Where? Who? Where are people to speak with?”

In contrast, “Suzan,” a 50-year-old woman from Syria at Softex camp in Thessaloniki, was able to access help from a mental health professional and said that it had helped her greatly: “I went to a doctor for my back, and told him that we were dying in Syria and how tired I am of life. When he heard this, he took me to a psychiatrist here in the camp. The doctor was very kind, gave me advice, and I am better now.”

Suzan said that the unsafe conditions in the camp and the daily worry of whether someone may harass her and her two children is the source of her depression.

For some, the trauma of what they experienced or witnessed in their war-torn home countries was the catalyst for mental health conditions. “Hannah,” a 47-year-old single mother of three, who together with her children was detained by ISIS in Syria for a week in September 2015, said: “My 11-year-old son still has psychological problems... [He] pees his pants. He is tall and robust but from the shock he is peeing his pants.”

Her daughter “Lamye,” 24, who was in her fourth year of medical school back in Syria, said she is having panic attacks: “I can’t sleep. When I got to bed I feel like I am in a tomb. I feel like I’m choking and dying. I hear discussions about the war and I run away.” Lamye said she now has an irregular menstrual cycle, which she attributes to the stress. She is one of only three people interviewed who reported seeing a psychiatrist or a psychologist twice a week.

Du’aa, a 56-year-old Syrian mother of three, witnessed a bombing in front of her home in 2013 that injured two boys. Du’aa and her daughter tried to rescue them but didn’t succeed and both boys died. Her son, Tarek, 25, told us, “She now has psychological problems because she couldn’t rescue them.” Following this incident, Du’aa began to display symptoms which were later diagnosed as Parkinson’s. She lost the ability to speak and has difficulties walking.

Since then, Duaa’s physical and mental health have deteriorated. Tarek said Du’aa did not receive any psychosocial support in Kara Tepe camp on Lesvos, where they were living until December 2016. “I am obliged to help her, talk to her, make her laugh, otherwise she would have negative thoughts all of the time,” Tarek said.

A representative of an international aid organization confirmed that because Du’aa can’t speak, they were unable to provide her psychosocial support. In December, Tarek told a Human Rights Watch researcher that the UNHCR has moved him and Du’aa to an apartment on Lesbos. 

Omar, the psychologist from WAHA, explained how difficult it was to provide psychological support to people who need it: “The basic rule in psychology is that the patient must change the environment around him and oblige himself to change his way of thinking. Here it is very difficult. I can’t make refugees accept the life under sun, rain, hot, cold...”

Perraki, the psychologist with MdM in Lagkadikia camp in Thessaloniki, described some of the practical difficulties in providing adequate mental health care to people in need: “We did not even have a safe space where people would come to and speak about their problems. We were working outside for five months, in the heat, flies flying around. Now, we finally received a [transport] container which provides us with a place where people can feel safe behind closed doors.”

A representative of one international organization said that some safe spaces in camps where women and children can receive psychosocial support are not accessible to people with physical disabilities: “For example there are no ramps to make them accessible,” she said.

While some aid agencies assert that mental health services have increasingly been made available in refugee sites across Greece since June 2016, they recognized that it is not sufficient.

Omar, who is working at Souda camp in Chios, which held 1,150 people when Human Rights Watch visited, said that the mental health of people in the camp is getting worse every day and that violence, inadequate food, and lack of access to education affects the mental well-being of migrants and asylum seekers: “The situation is getting worse and violence is everywhere, even against women and children. It is traumatic for all children here because every day there are fights.” Severe overcrowding, appalling conditions, lack of access to basic services, insecurity, and the failure of police to protect, are all reasons behind violence and harassment in the camps.

Access to Water, Sanitation, Hygiene Facilities

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The availability of accessible toilets is one need that aid groups have focused on, but even then only two of 15 camps of which Human Rights Watch has direct knowledge has ramps to the toilets, and uneven, rocky terrain and long distances prevented some people with disabilities from reaching these “accessible” toilets. One of the two camps that has ramps is a volunteer-run camp, PIKPA, on Chios.

“We have this wheelchair [for my 75-year-old father] but we cannot use it because of the terrain,” said a 25-year-old woman from Afghanistan in Moria camp.

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In Oreokastro camp in Thessaloniki, an 85-year-old Syrian woman in a wheelchair said she hadn’t taken a shower in a month because of the difficulties in accessing the shower area and there is no warm water. Human Rights Watch researchers observed a barrier to the entrance to the women’s shower area and steps in front of each shower.

The Schisto and Eiliniko camps in Athens and Lagkadikia camp in Thessaloniki had no accessible toilets or shower areas when Human Rights Watch visited in October.

Eight-year-old Ali from Afghanistan, who uses a wheelchair and lives in the Elliniko camp in Athens, did not have access to an accessible toilet. “It is very difficult for us to take him to the toilets,” said Ayesha, Ali’s mother. “I cannot do it by myself and other women in the camp protest if my husband enters the female toilet to help me with Ali. So we finally decided I would go to the men’s toilet, with Ali and my husband helping. Then, men got angry and protested, ‘Why is a woman inside a men’s toilet?’”

She said the toilets are also dirty and unsanitary. “We always have to first clean them before allowing Ali to use it.” Because of these problems, they made a difficult decision to put Ali in diapers when they can get them.

While families of people with disabilities play a crucial support role, people with disabilities have an equal right to access water, sanitation, and hygiene facilities in the camps, independently and with dignity.

Guardian analysis of data provided by the EU shows also that 19 camps receive no designated EU funding for water-related infrastructure such as toilets and showers.

Lack of Adequate Housing, Winterization
In January, temperatures in Greece have dropped to -5 degrees Celsius on Lesbos, and to -20 degrees Celsius in other parts of Greece. Heavy snowfall covered the tents in the Moria refugee camps on Lesbos on January 9, where thousands of asylum seekers lived, according to aid organizations. Media have reported that refugees, including children and people with disabilities, are freezing in flimsy tents.

In December 2016, the EU, the UNHCR, aid groups, and the Greek government were accused of failing to use €90 million worth of EU funding to “winterize” the camps before the first snowfall.

On December 22, the UNHCR told Human Rights Watch it had provided heated containers to eight government-run sites for refugees in Greece and that 21,000 people have been accommodated in apartments, hotels, or other buildings. The UNHCR confirmed, however, that many people continue to live in tents.

According to the UNHCR website, as of January 10, more than 33,000 asylum seekers and migrants continued to live in informal and formal refugee sites.

Winter and the freezing temperatures are a source of anxiety and stress for camp residents. The weather affects everyone, but particularly at-risk groups such as pregnant women, children, older people, and people with disabilities. Cold weather can also affect respiratory and circulatory systems, and it is especially hard for some people with disabilities to maintain body heat.

Mohammed, father of five children, including a 2-year-old boy and 13-year-old daughter with diabetes, have lived in Lagkadika camp in Thessaloniki since May 2016. In October, he expressed deep concern that despite dropping temperatures then, they had not yet been transferred from tents to containers. “We need [transport] containers now,” he said. “When my children wake up in the morning, their little hands are blue, like ice from the cold.” In a phone conversation with Human Rights Watch on December 21, a UNHCR representative said the Lagkadikia camp tents have been replaced by containers.

Delayed Access to Health Care, Lack of Adequate Medical Services
Among the biggest problems all refugees, asylum seekers, and other migrants face in Greece is access to timely and adequate health care. Hospitals even struggle to provide adequate health care for Greek citizens, due to the general breakdown of the health care system, and a lack of resources amid the economic crisis. For example, on Lesbos, there is only one permanent psychiatrist in the public healthcare system for the entire island population.

However, asylum seekers and migrants with disabilities, who might require specific health or rehabilitation services or assistive devices, face particular obstacles and often struggle to get medical treatment or specialized care. Those interviewed described prolonged delays in seeing a primary care physician in the camp, high transport costs to local hospitals, administrative barriers, lack of information, and general lack of availability of specialized services, including rehabilitation centers.

While Greek law has extended the right to free health care, including in local hospitals, to asylum seekers, Human Rights Watch found that asylum seekers, refugees, and other migrants with disabilities who need both primary and specialized medical attention are not able to access it. People who require orthopedic surgery, rehabilitation services, or medicines for chronic physical and mental health conditions such as epilepsy are particularly affected.

Five asylum seekers interviewed said they or their family members with disabilities had to wait up to a month to see a doctor in the camp. Tarek, the 25-year-old man from Syria who is supporting his mother Du’aa, 56, who has multiple disabilities, told us at the time of the interview that his mother had seen a doctor only once since they arrived in Greece in late August. “When we asked to see a doctor in Kara Tepe [camp where they are living] we were told to come in a month… Even the medicine she needs – I got it with so many difficulties.”

Davud, a 45-year-old man from Afghanistan in Schisto camp in Athens, has tremendous pain in his leg that keeps him awake most nights. He requires crutches to walk. He had been living in Greece for eight months but had not seen a doctor in a hospital yet. He said that doctors at the camp give him painkillers:

I went to doctors in the camp and they told me to speak with officials in the camp to get permission to go to the hospital but it has been three months since and nothing has happened. I went to ask again one month ago, then 15 days ago – nothing. Lately I’ve not been to doctors. It is crowded, they don’t see me easily. They only do painkiller injection, nothing else. I will end up having a permanent disability.

Twelve other people interviewed said that doctors in hotspots and camps just provide painkillers. A 25-year-old woman from Afghanistan said: “When I go to see doctors here, they just give some painkillers. Nothing else. Whatever problem you have, they give you painkillers.”

At Schisto camp in Athens, the father of Mahmud, an 8-year-old boy from Afghanistan, said that camp doctors had diagnosed the boy with kidney disease and said he needs treatment he cannot get in the camp. “I just want him to get well,” his father said in a trembling voice.

Human Rights Watch did not have an opportunity to investigate with medical staff the issue of available treatment in the camps.

International aid organizations on the ground confirmed the hurdles people face in accessing health care, including specialized care in local hospitals, partly due to administrative barriers. To get health care in the community, people have to obtain tax registration and social security numbers, but they are not told in the camps how and where to get the required documents. Some refugees with disabilities said that the lack of affordable transportation or access to information on where to get the needed treatment are other obstacles.

Getting assistive devices is hard for some people. Amin, a 24-year-old deaf man from Syria, in Lagkadikia refugee camp in Thessaloniki area, said that his hearing aids from Syria were damaged by water in the rubber boat when he crossed the Aeagan Sea in February 2016, and later by rain in Idomeni, on the border with Macedonia. Amin had received new hearing aids only two days earlier, in October. “The most difficult thing about the camp is that Amin feels isolated from everyone else,” his father said. “He prefers to sit in the tent alone or go around the camp alone because no one can understand him.”

Many chronic health conditions of people living in camps, such as hypertension, diabetes, epilepsy, and cancer, can lead to disability, increasing the number of people with disabilities. Access to rehabilitation services is particularly important to maintain physical functioning and to prevent deterioration from failure of early treatment and developmental disabilities among children.

Legal Obligations
The UN Convention on the Rights of Persons with Disabilities (CRPD) requires countries such as Greece, which became a party to the treaty in 2012, to ensure equal access to basic services such as sanitation, housing, schools, and medical facilities in the camps, including in emergency situations. Failure to do so is a form of discrimination. The treaty states that countries should ensure the protection and safety of people with disabilities in situations of risk, including situations of armed conflict, humanitarian emergencies, and natural disasters.

The European Council and Parliament Directive 2013/33/EU, which was transposed into law 4375/2016, sets out minimum standards for the reception of asylum seekers. It states that “the reception of persons with special needs should be a primary concern for national authorities in order to ensure that such reception is specifically designed to meet their special reception needs.” The directive also obliges member states to ensure that asylum seekers have access to necessary health care, including “at least, emergency care and essential treatment of illnesses and of serious mental disorders.” and “appropriate mental health care where needed.” EU member states also are responsible for taking into account the specific situation of vulnerable people, which includes people with disabilities and mental health conditions.

Methodology
The research presented here is based on interviews Human Rights Watch conducted between October 16 and October 23, 2016, with 40 refugees, asylum seekers, and other migrants, including two children, in five facilities on the islands of Lesbos and Chios, which at the time was accommodating more than 10,500 asylum seekers and other migrants, as well as in four facilities in Athens and the Attica region, four in Thessaloniki and the surrounding area, and two in the western Epirus region. The interviewees included 34 people with physical, sensory, intellectual, developmental, and psychosocial disabilities, or health conditions that might lead to disabilities, along with their families.

Each interviewee consented voluntarily to be interviewed by Human Rights Watch and none received any payment or other personal service or benefit in return for the interview. Names of some of the interviewees have been withheld to protect their privacy and security.

This report uses the term “person with disability” inclusively to describe those with long-term physical, intellectual, developmental, psychosocial, or sensory disabilities and those with mental health conditions.

Human Rights Watch also interviewed representatives from the office of the Greek ombudsperson, UNHCR officials, a camp manager, and representatives of the nine aid organizations.