Why the Refugee Crisis Is Just the Beginning

LESBOS, Greece—Two years after her town fell to the Islamic State, Zozan Qerani visited psychiatrists in Turkey and Greece for help with what she’d seen. Feelings she called depression had started to intensify, causing fainting spells as she moved along the trail to Europe, she said. Last week, at the camp on Lesbos, Greece, where she’s been living since March, a war now 1,000 miles away would once again threaten her life.

Since arriving in Greece by boat three months ago she has suffered seizures while living in a tent at a refugee camp called Kara Tepe. “I fall over, every day,” she said, sitting on a folding chair in front of the tent, which she shares with her husband, Atoo Qerani. An English speaker, he translated her Kurdish. She said she sleeps badly and has nightmares: “I see bad things.”

Zozan, 23, speaks in a whisper and holds her arms around herself tightly, seeming smaller than she is. On her left arm is a four-inch scar from a suicide attempt, one of at least three in recent months, Atoo said. The doctor who treated the self-inflicted wound, an M.D. working with a medical NGO at Kara Tepe, who was not authorized to speak to the press, characterized the attempt as “serious” and said Qerani would have died without treatment.

Zozan Qerani, a Yazidi from Iraq, sits in her tent at a refugee camp on Lesbos, Greece, on June 16. (Photo: Maro Kouri)

Zozan’s psychological challenges date to March 2014, when she was at her home in Siba Sheikh Khidr, a Yazidi town in Iraqi Kurdistan. Before escaping to Turkey, she said, she witnessed summary executions by the Islamic State and “many terrible things.” Asked to generalize about the experience, she offered a mobile phone opened to a Facebook page run by a Yazidi human rights campaign, showing graphic images of murders and beatings in Yazidi villages neighboring hers.

The claims and the images on the site appear consistent with incidents detailed in a U.N. Human Rights Council report released June 15 and based on interviews with 46 Yazidi refugees. “ISIS has committed the crime of genocide as well as multiple crimes against humanity and war crimes against the Yazidis, [who] are subjected to almost unimaginable horrors,” said the report.

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Being in administrative limbo has made it difficult for Zozan to seek treatment for her life-threatening medical condition and is adding to a mental health crisis that has led to suicides and depression and stands to overwhelm the continent's mental health systems, say aid workers on Lesbos and nearby Chios island. According to UNHCR, 215,380 people have fled war and autocracy by crossing the Mediterranean Sea this year, following a record 1,015,078 last year. The German Federal Chamber of Psychotherapists announced last year that more than 70 percent of refugees who reached Germany have witnessed violence; around 50 percent have experienced violence themselves. That figure holds for 40 percent of children; around a quarter saw violence against members of their family. As far back as 2013, UNHCR found that more than a fifth of Syrians in a refugee camp in Jordan experienced anxiety disorders, with 8.5 percent suffering from post-traumatic stress disorder. The German study found demand for psychotherapy among refugees just in Germany could be 20 times what is being delivered.

“We see the need for acute treatment right after they arrive in Germany, but also for long-term psychological and psychiatric care,” said psychotherapist Mechtild Wenk Ansohn of Berlin’s Center for the Treatment of Torture Victims, where she runs outpatient services. The Berlin center is currently operating at capacity—500 patients— mostly refugees who passed through the Greek isles before the Turkey deal, she said. Like their counterparts in Greece’s camps, Berlin’s refugees are under additional stress from uncertainty, causing some who had not needed treatment six months ago to present again with symptoms of depression. Ansohn anticipates her staff’s caseload will remain high for years.

Refugees are housed together in group tents at the Souda camp on Chios, Greece. (Photo: Maro Kouri)

“If these people leave, they go somewhere, and they carry this with them,” said Fenia Tsakona, director of services on Chios for WAHA, an Emirati NGO whose staff includes an Arabic-speaking psychologist, Syrian French doctor Amer Omar. “So if you see on a larger scale what’s going on, all this trauma is passed to everyone. It’s passed to me; it’s passed to Amer; it’s passed to their children.”

“They become stressed; they have an anxiety crisis, depression,” said Irene Kamboura, a social worker with the French international NGO Médecins du Monde who is based full-time at Souda, a camp on Chios housing about 1,000 people. “The referrals to the hospital are more often [than before the March agreement]. Once a week for sure.”

Trained as a social worker, not as a therapist, Kamboura sees about four people a day just to talk. Two other organizations, Praksis and WAHA, rotate psychologists at the site; Kamboura is the only counselor at the camp full-time and receives visits in part because she's most often the one available, she said.

“People are desperate to leave. Their families are elsewhere in Europe, so they want to go on,” Kamboura said, sitting in the hot tent where she holds sessions. In many cases trauma presents as a physical problem such as shortness of breath, but the camp’s general practitioner refers patients for psychological care: “They go to the doctor because they don’t feel well, their chest hurts, but then they come over here to talk to someone.”

There have been two suicide attempts requiring hospitalization at camps on Chios in June, both unsuccessful, said Tsakona. She arranged for Omar to treat the two people, who returned to the camp after stays of four or five days at Chios’ public hospital. Local hospitals handle the initial response, Omar said, but refugees are quickly sent back to the camps. He continues to see the two who attempted suicide, treating them in their tents and a small medical clinic at the camp.

As part of the Turkey deal, refugees can apply for “vulnerable” status, which allows some psychological cases, as well as single parents with children, unaccompanied minors, people managing chronic disease, pregnant women, and the severely mobility impaired to qualify to live at camps like Souda that have greater support structures, including psychological services.

Three hours away on Lesbos, Zozan Qerani met the standard for “vulnerability,” which allowed her a space at Kara Tepe. But resources are insufficient even in these special camps, and local medical systems—themselves decimated by cutbacks as a result of Greece’s euro crisis—typically have capped psychiatric treatment even for their own citizens, said Ipioti.

Greece’s hospitals do not have the capacity to handle the refugee cases, and neither do the camps, she said. “We can’t support the psychiatric cases, but it is a cap from the government; there are no places for psychiatric cases in the whole of Greece. Neither for the Greek people nor the refugees.”

Refugee children learn English at the Pikpa camp on Lesbos. (Photo: Maro Kouri)

Until the Turkey deal, the problem was manageable even without support from cash-strapped hospitals. “Before the agreement the most vulnerable used to come [to Pikpa], and most people would move on in one or two days” for points north, Ipioti said. (Such was the case with the Syrian war veterans whose story of escape TakePart published last year.) After the Turkey deal stranded at least 5,000 on Lesbos, Pikpa, which looks like a small children's day camp, the walls decorated with bright paintings of flowers and the slogan “All Together” in various languages, was insufficient. “The problem is, we have cases [across Lesbos] that need a more peaceful environment, and it’s not possible.... We’re talking about 1,000 people.” Referrals to the more individualized care at Pikpa stopped in mid-June after several transfers provoked suicide attempts among people who had filed requests but were not yet moved.

“It was ‘Why you let him go, and why don’t you pay attention to me?’ ” Ipioti continued. “The problem with these depression cases is keeping them inside [the camp] makes them worse.” The long stays have forced a collapse of the referral system. Demand for trauma evaluations is greater than the supply of volunteer doctors. “There isn’t someone to give them the pills,” Ipioti said.

With hospitalization impossible in the overwhelming majority of cases, even refugees who get access to a qualified psychologist at the local hospital or an NGO often receive only a quick diagnosis and a prescription and are left to self-directed treatment in the camps, she said.

Zozan was prescribed diazepam, which is sometimes used to treat anxiety. She takes it three times a day, but it has not helped, Atoo said. She continues to live in a small tent at Kara Tepe with minimal medical oversight, mostly cared for by her husband.

With drownings continuing across the Mediterranean, worrying about stress among the survivors seems like a luxury. But the strain of months-long stays in refugee camps has started to show in ways that are disrupting daily life and causing tension.

“I don’t like the Muslims,” Zozan said. “I don’t like living here with them.” Her Yazidi religion is a syncretic mix of Zoroastrian and other beliefs. The majority of refugees at Kara Tepe, home to about 875 people—mostly Syrian, Iraqi Arab, and Palestinian—are Muslim. She said she feels “surrounded” by the people she watched murder her neighbors.

Atoo Qerani. (Photo: Maro Kouri)

Atoo said he recognized that their fellow residents were unrelated to the Islamic State or the Iraqi government and probably victims of militants too. But he found it hard to shake associations between Islam and his wife’s trauma, he said. “After what we’ve been through, it is difficult. It makes you nervous,” he said.

As he was saying that, Zozan fainted, slipping off the folding chair.

“This happens every day,” a doctor on station from MSF told Kouri. Five minutes into the seizure, no medical response had arrived.

Zozan Qerani rests after suffering a seizure on June 16. (Photo: Maro Kouri)

A young volunteer from the International Rescue Committee, a broad-based crisis response NGO, appeared a few minutes later, saying she had heard of a problem. “Do they speak Arabic? Is there a doctor? What do I do?” said the woman, who gave her name as Yara and said she worked as an Arabic-English translator. She said she had only been at the camp four days and did not know the correct procedures, then left to find a superior. Members of the IRC team came and went for the next few minutes, seeming to lack a plan for responding to medical emergencies.

As Zozan lay on the pallet, her condition worsened with the passing minutes. Still unconscious, she attempted to choke herself, wrapping her hands around her throat and hooking her thumbs into the airway before her husband pried her fingers back and pinned her arms beneath his body. She screamed and began thrashing again, and the seizure abated.

Atoo applied gauze to Zozan’s palms at the base of her thumbs, where her tensed hands had caused her to cut herself with her fingernails, reopening sores from previous attacks. In a minute more, she calmed and slept peacefully.

Atoo believed Zozan recovered faster when awake, so he did something he had done following previous seizures: He got a cup of water and splashed it on her face. She awoke as if to a hypnotist’s finger snap. After orienting herself, she sat up, breathed deeply, and rubbed her muscles, drawing her legs up to her chest.

Atoo stroked her hair. “I’m a very good husband, no?” he said. The bit of clowning worked; Zozan returned a small smile and gave a laugh. She wiped the tears off her face and leaned against Atoo to rest. The episode lasted about 15 minutes.

Each transition presents a fresh trauma.

“Losing their homes, losing parents, fleeing, that’s the initial trauma,” said Michael Eder, an Austrian psychotherapist specializing in trauma, who has been volunteering at Pikpa since the winter. “Then the crossing, the smugglers. Anxiety attacks while they are arriving.” As the boats landed, people often jumped too early or fell in the water, and anxiety attacks made breathing while swimming impossible. They could drown just a few yards offshore. With all the immediate needs for arrivals, Eder said, it is like “triage in a war zone.”

Because of the new bureaucratic delays, doctors now see the same patients for at least a few weeks and sometimes months, and have begun to construct some psychological profiles of trauma resulting from long-term residence in the Greek camps.

One boy of seven had lost his appetite and all but stopped eating, said Kamboura, the social worker on Chios. In that case, after the boy’s father came to her for advice, she began a series of informal discussion sessions with the child, who is from Syria, talking to him about his family and his daily life and simply giving him individual attention amid the crowded camp.

Alia’a Marastawi looks after her daughter and her niece in a group tent at a camp on Chios on June 17. (Photo: Maro Kouri)

“Now that the people are staying here one, two, three months, they know me,” Kamboura said. “They are like friends. They want to speak with me; they need it. I know exactly their anxieties.”

The boy began eating normally and regaining weight after a month of her informal therapy, she said. She continues to monitor the family and stays in touch with the father, who is awaiting a ruling on his family’s asylum case. They live in a tent about 50 yards from Médecins du Monde’s clinic.

Kamboura finds it difficult to offer coping mechanisms when her patients’ fears are justified. There is no indication their cases will be resolved soon; they may well be deported in the end. “And it’s hot during the day, and people are very, very bored. We’re giving out a lot of condoms,” she said.

Mysterious fires are common in the brush beside the sleeping area of her camp, the result of playing with lighters and, perhaps, a sign of frustration. In early June, a fire reached a large barn-like structure hosting about 30 families, who had to flee. The building was destroyed. “The children aren’t sleeping now. They’re scared from the fire,” Kamboura said.

The more the stress builds, the more it feeds on itself. Ahmad Marastawi, 33, a pharmacist from Aleppo, Syria, was swept up by Greek police after the fire. He claimed he was not near the structure when the fire broke out and was freed for lack of evidence after three nights in jail. “People start getting angry at anything. A little thing makes you angry,” he said. “People stay waiting, waiting, waiting, and don’t know what’s in the future. And that’s very complicated for a human being.” He feels his temper is getting shorter. “I control myself,” he said.

Ahmad Marastawi, 33, is a pharmacist from Aleppo, Syria. (Photo: Maro Kouri)

His wife, Alia’a Marastawi, said she had not been told when Ahmad would be released from jail and feared he could be deported, which was unlikely, but that was not explained to her, she said.

“We went to the jail, and I worried, because Limar”—the couple’s one-year-old daughter—“sees her daddy behind glass; it’s very confusing.”

Like the refugees, Greek residents of the islands have been forced to manage their own uncertainty over the future of the camps—and don’t always handle it well. In June, after some fruit was stolen from an orchard near Chios’ Vial camp, residents blockaded the area with bulldozers, fearful that refugees would start attacking the neighborhood.

“We lock the door. We feel scared because we don’t know. Maybe they become desperate, and hungry and come to the door, come inside the house,” said Maria Kouneli, who lives in the blockaded neighborhood.

An owner of the travel agency where Kouneli works, Michael Kolokythias, said he felt frustration building elsewhere on the island of just over 30,000 residents, now with three refugee camps hosting about 2500. Kolokythias had been an immigrant to Canada before returning to Chios. “I understand being a migrant. We understand. It was raining one day, so I bought 60, 70 umbrellas and handed them out to women with children.” But his business has fallen by 80 percent since the refugee crisis began—Chios, an island of hidden beaches and medieval villages, depends on tourism—and his creditors aren’t letting him delay payments on loans.

“We built businesses, and we faithfully paid our loans, and then this happens and we lose a season. People become very stressed, and it affects us,” he said.

On June 21, the Greek coast guard announced some of its officers and local port officials would be participating in courses on “burnout syndrome– Traumatic Stress Disorder” offered by a Lesbos hospital and a local college.

Greece, however, has challenged their limits, psychological and physical, according to several members of both teams.

Lifeguard Manuel "Lolo" Vidal hugs Lyn, a Syrian girl who, after her crossing from Turkey, was terrified of the ocean until Vidal gently escorted her into shallow water and played with her. (Photo: Maro Kouri)

A climate scientist, Manuel “Lolo” Vidal, 50, is one of the few members of the lifeguard teams whose career has not prepared him for the emotional impact of rescue work. “One day, two [refugees] got out of the boat and had heart attacks. Just wham—gone,” he said. “You pick up a child. No legs. You take a baby—its arm is broken in two places.” Even at home, during breaks, the experience on Lesbos disorients him. “When I go home and I’m driving in a roundabout in Seville, I think, maybe I should just stop by Moria [a refugee camp on Lesbos]. Or maybe I should pick up that guy—he looks Pakistani; maybe he needs a ride to town.”

Vidal said he had made his own arrangement with a friend in Seville who is a psychologist; he saw her before and after previous stints in Greece. “Just like you prepare physically, you prepare mentally.”

The shortage of trained mental health staff has resulted in a surprising source of consolation to the rescuers, as many of the camp volunteers are now serving in ad hoc arrangements as amateur trauma counselors. The Spanish rescue teams give swimming lessons to refugee children, many of whom are scared of the water.

“At first, you pick them up and they are like little raccoons, terrified,” said Vidal. “They’ve seen people drown. They lost someone—their mother, their cousin.” He said the swimming lessons helped him cope with what he’d seen. “In theory, this should be a house of horrors. But it’s where you feel the best.”

“All of us have a job waiting for us on a beach, and we chose to be here,” said Anabel Montes, a beach lifeguard for 11 years who is now part of Proactiva’s permanent team on Lesbos. She said she had learned to think of failed rescues in the larger scheme of the team’s successes. “You have to assimilate it,” she said, and reserved her frustration for the political situation, which has limited rescue services to charity-funded NGOs like hers, though larger vessels from the Greek navy, the European border patrol agency Frontex, and several NATO vessels are nearby but not involved in rescues. “They’re politicizing a humanitarian job,” she said, frowning.

Yara Shlewet, a volunteer with the Palestinian aid group Humanity Crew, teaches English to Arabic-speaking refugee children on Lesbos. (Photo: Maro Kouri)

On June 16, Vidal and a sea rescue team from Seville took about a dozen children to an Aegean beach near Pikpa camp, where discarded life vests and the husks of inflatable smuggler’s boats still cling to Lesbos’s jagged coves. Vidal focused his attention on an eight-year-old Syrian girl named Lyn. With her mother and an infant sibling, Lyn was separated by gun-wielding smugglers from her five other siblings as they all waited on a beach in Turkey to be taken to the smugglers’ rafts.

The other children are now in Germany, according to two aid workers familiar with the case, but Lyn, her mother, and the infant are stranded in Greece.

Lyn had not wanted to return to the water, said Vidal. With the mother’s permission, he took her to the beach. He carried her into a calm part of the Aegean’s mirror-like water and held her above it while spilling drops on her head, a few at a time. Over about half an hour, he added more drops, then handfuls, of water. By the end, the girl was wading with him and splashing.

Several volunteers in the camps spoke of an oddly alluring quality to the experience, and of ambivalence over leaving it—and recognize that the call back to the island is not always rational. “I’m addicted to working with the refugees. I don’t know what I’d do if I wasn’t,” said Kamboura.

“I was supposed to leave tomorrow,” said Yara Shlewet, 23, a special education teacher from near Haifa, Israel, with the Palestinian aid organization Humanity Crew. Shlewet teaches English and Arabic at Pikpa, where some children have been on the road long enough to miss most of their primary school years. “I’m staying another two weeks, and then, I don’t know. When I’m at home, with my laptop and my air conditioning, I don’t know how that will feel.”

Following Zozan Qerani’s seizure, three IRC volunteers suggested she walk to a special area of the camp for women. It offered “tea, comfortable chairs, a quiet space,” one of the volunteers said.

Zozan, still lying on the cushioned pallet, glared at them and shook her head no. “It’s the first time they offer me this. They do this because you are here,” she said, pointing at Kouri, the photographer.

Tea wasn’t going to help, she said. What she wanted was a transfer out of the camp. A limited number of hotel rooms in nearby Mytilene are available for refugees showing acute cases of “fragility,” as determined by the UNHCR.

“To me she is a clear candidate,” said the doctor who treated Zozan after her last suicide attempt and was not allowed to speak to the press. “But it is not my decision; we do not control it. It’s up to UNHCR.”

Of the 5,000 refugees on Lesbos, about 20 percent qualify for UNHCR’s “fragility” designation, allowing them to reside in the Kara Tepe and Pikpa camps—if there’s room. Both are near enough to capacity that any new cases requiring psychological support will soon overwhelm the available resources. Kara Tepe has about 250 spots left, with boats carrying dozens of people still arriving weekly. With an estimated 3 million refugees in Turkey, no end in sight to the Syrian war, and unresolved conflicts continuing in Iraq and Afghanistan, it’s anyone’s guess how many will take their chances and try to make the crossing.

Zozan Qerani tries to break through a police line during U.N. Secretary General Ban Ki-moon's visit to Kara Tepe refugee camp on June 18. (Photo: Jodi Hilton/NurPhoto via Getty Images)

On June 18, U.N. Secretary General Ban Ki-moon toured Kara Tepe camp. The Qeranis, who said they learned of the visit an hour earlier, joined a small demonstration on behalf of Yazidi refugees. Ban was ushered with international press to an enclosed area to meet some children and adults living at the camp. The protest of a few dozen people was kept a short distance away, behind a fence. Zozan was at the front, shouting and yelling.

After the meet and greet, the U.N. leader passed the protest, and Zozan lost her composure. In a wire service photograph, she is visible pushing against a police line protecting the visiting dignitaries, screaming and resisting, while attempting to pass Ban a letter Atoo had drafted requesting more U.N. attention for Yazidi refugees. As she hurled herself against the police line, Atoo attempted to cover her mouth, thinking, he related later via Facebook message, that she was overreacting. Stavros Mirogiannis, the camp manager, tried to calm her, telling her the camp residents were a family and at one point kissing her hand.

The soothing failed. Zozan was nervous and agitated and within a few moments fainted. A seizure began, lighter and shorter than the one a few days earlier, and with camp doctors nearby, she received medical attention. She soon recovered and told bystanders, some of whom said they suspected she'd faked the attack—camp doctors confirmed she had not—that she was fine. Ban made no comment about the protest.

As of June 22, the couple’s asylum status and relocation request remained unresolved.