High-income countries have been adopting increasingly restrictive immigration policies and practices over the last decade, including the systematic detention of undocumented migrants and asylum seekers. Such policies are now implemented by middle- and low-income countries as well (e.g. Mauritania, Libya, South Africa, Turkey). In some cases detention facilities are actually financed by high-income neighbouring countries (e.g. Spain financing immigration detention facilities in Mauritania or the European Union financing immigration detention facilities in Turkey and Ukraine).
Many asylum seekers and migrants arrive in relatively good health, despite their difficult journey. However, once in detention, their health soon deteriorates, at least in part due to substandard detention conditions. Recurrent issues observed by MSF teams included overcrowding; failure to separate men, women, families and unaccompanied minors; poor hygiene and lack of sanitation; poor heating and ventilation. Shelter was often substandard, with some people detained in containers, in rooms with broken windows or even outdoors, sleeping on wet mattresses on the ground. In addition, detainees had very limited or no possibility to spend time outdoors. In nearly every detention centre there was no facility for isolating patients with communicable diseases.
The most frequent illnesses were linked to the lack of systematic and/or preventive medical care. Respiratory problems were often linked to exposure to cold, overcrowding and lack of treatment for infections. Skin diseases including scabies, bacterial and fungal infections reflected overcrowding and poor hygiene. Gastrointestinal problems including gastritis, constipation and haemorrhoids could be a result of poor diet, lack of activity and high stress. Musculo-skeletal complaints were among other things linked to limited space and exercise and a cold, uncomfortable environment.
“What we witness every day inside the detention facilities is not easy to describe. In Soufli police station, which has space for 80 people, there are days when more than 140 migrants are detained there. In Tychero, with a capacity of 45, we counted 130 people. In Feres, with a capacity of 35, last night we distributed sleeping bags to 115 detained migrants. One woman who had a serious gynaecological problem told us that there was no space to sleep and she had no other option but to sleep in the toilets. In the detention centre of Fylakio, several cells were flooded with sewage from broken toilets. In Soufli, where winters are known to be harsh, the heating is not working and there is no hot water. In many detention facilities, we saw many unaccompanied minors detained in the same cells as adults for many days without being allowed out in the yard.” (MSF humanitarian worker in Evros, December 2010)
The context of detention poses additional significant challenges for asylum seekers and migrants with chronic medical conditions, disabilities or mental health problems. Patients already under treatment for a medical condition often had to interrupt the treatment upon being detained because of lack of access to their medication and/or inadequate medical care in detention. In the centres where MSF works, medical services were either not provided or were gravely lacking. Furthermore there was no system in place for the screening and management of vulnerable persons such as persons with chronic health problems, victims of torture, victims of sexual violence and unaccompanied minors and the facilities were not adapted for use by persons with limited mobility.
Impact on mental health
Detention increases anxiety, fear and frustration and can exacerbate previous traumatic experiences that asylum seekers and migrants endured in their country of origin, during the trip or during their stay in a transit country. Their vulnerability is further aggravated by uncertainty about their future, the uncertain duration of their detention, and the ever-present threat of deportation. Difficult living conditions, overcrowding, constant noise, lack of activities and dependence on other people’s decisions all contribute to feelings of defeat and hopelessness.
In all detention centres, a high percentage of MSF patients mentioned previous traumatic experiences. In Belgium in 2006, for example, 21% of patients reported suffering physical abuse prior to arrival while many reported having witnessed deaths of family members or fellow travellers. In Greece in 2009-10, 17.3% of patients sought psychological support for traumatic experiences. In Malta, 85% of MSF patients who suffered from mental health problems in detention had a history of trauma prior to displacement. Many had witnessed people dying while crossing the desert or drowning crossing the Mediterranean.
Detention came as a shock to most of them, as they had very different expectations and found it very difficult to cope with being restricted in often overcrowded cells, with no or very limited time outside and no private space at all. Detention was the precipitating factor for the mental health complaints of over one third (37%) of migrants according to the symptoms recorded in MSF patients in Greek immigration detention facilities during 2009-10. Symptoms of depression or anxiety were diagnosed in the majority of patients in all centres where MSF intervened.
Despite these obvious mental health needs, most detention centres where MSF had to intervene completely lacked mental health services. Even when mental health-care services were introduced, these were insufficient and not adapted to the specific needs of migrants and asylum seekers, for example with no interpretation service available.
Working in closed settings like prisons or detention centres poses ethical challenges for humanitarian organisations because of the risk of being perceived by detainees as complicit in the detention system. Thus this work requires a high level of responsibility and vigilance to safeguard the interest of patients’ physical and mental health, in a context where operations fully depend on the consent of the state. Negotiating and maintaining access to these facilities (which are often closed to external scrutiny) is essential, as is being able to raise awareness through public advocacy on the health and humanitarian consequences of restrictive migration policies.
Based on MSF’s operational experience, we can only conclude that immigration detention undermines human dignity and leads to unecessary suffering and illness. Due to the disproportionate risk it presents for individuals’ health and human dignity, it is a practice that should remain the exception and not the rule. The widespread and prolonged use of immigration detention should be carefully reviewed by policymakers in view of its medical and humanitarian consequences, and alternatives should be considered.
Ioanna Kotsioni Ioanna.firstname.lastname@example.org is Migration Advisor for MSF in Greece; Aurélie Ponthieu Aurelie.email@example.com is Humanitarian Advisor on Displacement at the MSF Operational Centre, Brussels; and Stella Egidi Stella.firstname.lastname@example.org is Medical Advisor for MSF in Italy. www.msf.org