ORGANIZING MEDICAL CARE TO REFUGEES AND MIGRANTS OUTSIDE THE SYSTEM – An experience from the Balkans' Route No.2

 ORGANIZING MEDICAL CARE TO REFUGEES AND MIGRANTS OUTSIDE THE SYSTEM – An experience from the Balkans's Route No.2

Dimitar Anakiev, MD
spec.Global Health

First of all why organizing medical care outside the system? And second, what does it really mean? Few days ago a group of volunteers in Velika Kladuša were discussing impossible situation that government of B&H as well as EU government(s) do not allow helping refugees and migrants that stuck in Bosnian Frontier. At the moment they are about 4000 of them just at the Frontier (3000 in Bihać and 1000 in Kladuša) while in all B&H estimated number goes over 10.000. Everyday new 400-500 refugees and migrants cross Serbian/Bosnian border while about 50 of them try each day to continue their way to EU crossing Croatian border with very small chances to avoid being pushed back, beaten and humiliated by Croatian police defending the Fortress of Europe. All volunteers discussing the situation agreed that the similar political will can be recognized in decision of not receiving boats and ships with refugees rescued from the open sea into the European ports and in prohibiting health care to refugees and migrants stuck in Bosnia and Herzegovina. Prohibited are both regular health care of the system and humanitarian health care (MSF is in place many months but without permission to work; it is playing taxi service to local doctors occasionally delivering health care to refugees and migrants beyond the legal procedure...In Bihać, we have heard, doctors from the Health Center do not want to work with MSF because of low payment. More than one month MSF do not buy drugs in local pharmacy and their container in the refugee camp Borići is closed with the inscription „We are not here for the moment“...) Here we have the answer to the first question: organizing health care outside the system is the last line of defense of human lives and also human dignity and rights. That simply.
Not much more complex is to describe what does it mean and why it happens. We face two main problems at this point:

1. Confrontation with the (political misuse of) police
2. Problem of constitution and self-organization of medical unit

In the regular meeting between Kladuša's  police chief with the camp Trnovi's coordinator that took part on 8th of August 2018, the police chief expressed his opinion that „doctor-volunteer in camp is illegal“. Even if we forget human rights this statement is actually illegal because Federation B&H Health Care Act orders „No one is allowed to endanger human life“ and „in an emergency situation each person is obliged to deliver first aid to wounded or ill people in accordance with own knowledge and abilities as well as helping them of reaching the nearest healthcare institution ( Article No.3). At this point no one physician will have doubts in legality of voluntary delivering medical care in accordance with the situation and abilities. The pressure is more on the side of camp coordinator who must bear the tension of possible confrontation with the politically influenced police he/she usually must collaborate with. This pressure tends to affect the organization because doctor alone, doctor who is not supported by medical unit, cannot really use her/his knowledge in the best possible way. The „spontaneous“ solution: „Do not worry doctor, we will help you as much as we can, just go to the camp and heal people“ has significant limits.
The most basic medical unit has two members and car. Two members of the medical team are doctor and nurse. Also possible combination is doctor and medic/paramedic or doctor and community health worker (CHW) but in that case the CHW must be trained for work in the situation. Medical team without doctor would have very limited goals because only doctor has special authorization and he/she can take full responsibility over the health situation including documenting and advocacy of the patients...At this point it is necessary to stress that medical work is autonomous by its nature, it cannot be subordinated to other sectors but independent and self-regulated in all important questions.
The most simple car needed is minivan or van – second hand or borrowed - a little bit more ambitious is motorhome. Medical team will build the storage for drugs and establish network of collaborators regarding LAB, ECG, RTG and other diagnostic or therapeutic procedures to the level they need according to the situation. In Slovenia in 2016-2017 we formed a network of volunteers, sponsors and donors among private sector medical actors. This network supported our medical work with refugees and migrants coming from the Balkan's Route No.1 much better than public system controlled by restrictive policy. It is usually needed to get connected also with the institution of healthcare in the community because medicine is not an isolated activity. Even in condition of negative political atmosphere and legal restrictions there are always medical workers, particularly among doctors, but also among nurses, with independent, professional/human and responsible posture able to listen and understand colleagues working with people in hard conditions.
If medical team voluntarily help the refugees and migrants than the cost of medical care is reduced to formula: cost of drugs & equipment plus overheads. That seems to be bearable of self organization.
Reason of organizing medical care outside the system lies in confrontation with official politics towards refugees and migrants and political motivation in general. It goes beyond humanitarian work which is usually limited to the neutral position for the reasons of being somehow incorporated into the system. But what if political system establishes inhumane principles? That is our situation and this situation is totally political, that is why it requires politically motivated medical crew being conscious about political situation and political mistreatment of their patients. Because only politically motivated doctors and nurses can take risk of confrontation with political system and of working outside the system. Being neutral in such political situation means to collaborate with the system which openly and massively endangers human lives.
If police in Kladuša continues to treat voluntary medical work in camp Trnovi as illegal then probably they consider refugees and migrants as prisoners of war. In such case principles of Geneva Conventions must be activated to support doctors and nurses in medical treatment of war prisoners.