As Syrians Integrate into Europe, New Healthcare Challenges Emerge

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I have been roped into another clinic shift on Saturday morning in the Container Exchange (CONEX) in Tulln at the camp. The doctor volunteer I’m covering for is sick. To my surprise most of the flüchtlingen (asylum seekers) are mothers and children. There are even some Austrian children with their moms, I recognize them as Red Cross volunteers who teach German classes. The kids play together in the waiting area, Austrians playing with Syrians, Afghanis, and Somalis, some standing and watching, others completely engaged. Kids do not see color, race, or language, they just see other kids.

The well child exams predominate. I start each encounter with the same question to each child, what are the first three flowers of spring? An Austrian boy runs around the barrier into the exam room to help his friend, “Schneeglöckchen, dann Primeln, dann Krokus!” (Snowdrop, then Primrose, then Crocus). The Syrian boy is sheepish, shy for not knowing. The Austrian boy is scolded and called back to the waiting room by his mother. The flowers come in sequence, the same every year, and somewhere between primrose and crocus the birds start to sing in the trees. For a Syrian this is about learning and integrating into a new society. This is Asylum Spring.

On the 26th of January 2016, the Austrian Government Ministers approved a new bill that stipulates that once granted asylum, a refugee’s situation should be examined after three years to determine if they are still at risk in their homeland, and if they are not they could then be deported. However, if the refugee in question is well integrated in Austria and there are humanitarian reasons why they should not be sent home, then deportation is unlikely. The bill also imposes a cap on those filing for refugee status at 37,500 for this year. Many of these folks will not report regardless; they have no incentive.


Meanwhile, the EU is closing the taps. Routes and borders into the EU through Hungary and the Balkans have been closed. Calais and the islands of Greece are still ports of call, but pressure is being applied there too. ‘The jungle’ camp in Calais was recently bulldozed. In Macedonia, police are rounding up and returning asylum seekers to Greek camps. Angela Merkel’s open door policy is facing stiff resistance. Even the current funding of Turkey to house refugees and return them from Greece is a stopgap measure. Attacks in Paris and Brussels only feeds further resistance.

This is most evident in the rise of the Alternative für Deutschland (AfD) party, which recently garnered 11.5% of the vote in German elections. This far-right, anti-immigration party started in 2013 in protest to Germany’s handling of the eurozone currency crisis. The party mobilized blue-collar workers (forty percent having never voted before in elections) against the immigration of flüchtlingen.

It is unclear if the press is fueling this controversy in Europe by selecting stories that reinforce schisms. What is clear is the rumbling report of the rise of Fascism, or neo Fascism, and more concerning is the description of asylum seekers as migrants. Both of these ideas inflame members on both sides of the fence.


As the borders are reinforced, asylum seekers are amassing there. MSF and UNHCR are reporting deteriorating health conditions at these informal camps. The WHO director reported that the greatest risk is not from migrants bringing infectious diseases to the EU but vice versa. Most new HIV cases in migrants came via sexual transmission with Europeans.

In August 2015, the EU commission tasked the European Center for Disease Prevention and Control (ECDC) to generate a plan for screening, vaccination, and health education of asylum seekers. Each country has managed the screening differently, and only tuberculosis screening has been universal. Italy proved to have performed best so far; they screen for hepatitis B, hepatitis C, HIV, sexually transmitted diseases, vaccine-preventable diseases, cholera, and malaria. Italy is also tracking cases of bloody diarrhea, watery diarrhea, fever and rash, meningitis/encephalitis or encephalopathy/delirium, lymphadenitis with fever, botulism-like illness, sepsis or unexplained shock, hemorrhagic illness, acute jaundice, parasite skin infection, and unexplained death. The advantage of this program is that it ensures follow up and tracking of asylum seekers once they arrive at their country of refuge. Italy therefore, has set the standard that the EU and the ECDC recommends.

As the asylum seekers remain at closed borders, local outbreaks of lice-borne diseases are anticipated, typhus being an example. If these refugees are a disease risk, will they be rejected, subject to ‘healthism’ or illness prejudice, or as some refugees are similarly claiming, racism? The question remains, how responsible should the EU be to the now unwelcome asylum seekers? Current causes for health-related rejection includes active tuberculosis, sexually transmitted diseases that are untreatable, and mental illness.

Currently in the camps in Turkey, Greece, Macedonia, France, Austria, and Germany the predominant diseases are viral. Both children and adults have to deal with gastroenteritis. Bronchiolitis in the young and bronchitis in the old due to crowding is common. If the asylum seekers have diabetes, asthma, and/or chronic obstructive pulmonary disease, viral diseases quickly develop bacterial super infections. Refuse that has accumulated and is not properly discarded by the refugees become additional foci for infection. I have approached UN, WHO, MSF, and even an British MP that have toured the camps to obtain epidemiology data, but the lid remains tightly in place on disease specifics, and some report that this is because the data is limited.


The greatest burden and the most communicable, however, are psychological disorders. It is the number one problem, and the least addressed. The trauma of displacement, prior torture, rape, PTSD, isolation from family, cultural estrangement, and a growing sense of hopelessness permeates the asylum seekers. These are prevalent in all refugee camps not just now, but well documented in the past. Cultural ambassadors work with mental health personnel to coordinate care and foster understanding. Talking about it can alleviate or exacerbate symptoms creating ‘Angry Young Men.’ This is what frightens local populations. Ultimately, the decision to allow flüchtlingen to enter the EU is made by police rather than by healthcare personnel and this may be a problem down the road.

Some of the kids in my clinic are war orphans. Their parents were killed, and they came on their own to Austria. The fortunate ones have been placed with foster families. Others are finding their way to the streets, living in the large cities, Graz, Linz, Salzburg, and Vienna. I recently met a Syrian Electrical Engineer working and staying with some folks. His family back home is suffering. He blames Assad, and sees other tribal factions and ISIS itself (that have carved up the country into fiefdoms) providing no better alternatives to national leadership.

Fortunately for flüchtlingen temperatures are rising nation wide; it is Spring, and for a while they should be okay. They will get to witness flowers, birds singing, which for the most part never happens in the desert and wastelands from which they escaped. At least the skies are not filled with jets and barrel bombs but black birds and doves.


Keith A. Raymond, MD has practiced medicine in 8 countries in 4 languages. He currently lives in Austria assisting Asylum seekers with the Red Cross. He has multiple journal publications and is writing his first two novels.

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