The protectors of refugee children

They are probably the first and only doctors to examine young refugees who arrive in Athens. The pediatricians Stavroula Dikalioti and Smaragda Papachristidou - due to their efforts and personal interest - have managed to facilitate the refugees’ access to public health, which is provided at no cost, but remains a complicated maze to navigate.
August 30, 2021
The protectors of refugee children
They are probably the first and only doctors to examine young refugees who arrive in Athens. The pediatricians Stavroula Dikalioti and Smaragda Papachristidou - due to their efforts and personal interest - have managed to facilitate the refugees’ access to public health, which is provided at no cost, but remains a complicated maze to navigate.
August 30, 2021

Photographs: Nefeli Pitta
Edit: Stavros Malichudis
Translation: Gigi Papoulias

They feel like doctors on a humanitarian mission. Their patients are mainly children of refugee families, who live either in apartments, reception centers or are homeless. The doctors are aided by interpreters provided by the hospital. In their office, the doctors have written a list of useful words and phrases in Arabic and Farsi.

In recent years, Dr. Stavroula Dikalioti and Dr. Smaragda Papachristidou, two pediatricians at Athens General Children’s Hospital “Pan. & Aglaia Kyriakou” in Goudi, (one of the largest pediatric hospitals in Greece), have been working as a team quietly and steadily to provide, as much as possible, full and affordable care for children and families. They examine 10 to 15 cases daily, at least two of which are vaccinations that need updating. Often, the patients are unaccompanied minors, who are undocumented and don’t have Greek social security number.

“When you find out that because of your intervention, a homeless child, who had been sleeping on a park bench, will be placed in a hostel, it’s obviously our priority,” says Dr. Dikalioti, a pediatrician and academic fellow at the pediatric clinic of the University of Athens’ Department of Nursing. “We don’t check our appointment book to see if the day’s appointments are already filled. If we are needed, we take action immediately.”

For Dr. Dikalioti, caring for children among the refugee population was an unfulfilled childhood dream. Finally in 2013, she started treating mostly refugee children at Aglaia Kyriakou Hospital. “Because I have a family, I was unable to leave Athens to work on a mission, so the children came to me,” she says with a smile. “They’re the reason that I continue to be here at this hospital. For me, it’s rewarding.”

In the beginning, the clinic served families who could not afford to buy the vaccines for their children’s scheduled vaccinations. But doctors soon realized that the children needed additional medical attention. Families were not adequately informed about proper nutrition for their children, or arrived at the doctor’s office exhausted by travel and poor living conditions.

Although most of their cases could be described as routine visits, such as vaccinations, during the usual 20-30 minute appointment, the two pediatricians have learned to be “detectives” looking beyond a patient’s short and hesitant responses. They try to detect deeper and chronic problems, which patients are often unable to communicate.

“We’re probably the only doctors that they’ll see in Greece. So, when you realize that you are not the first, but the only one who will treat the patient, you feel a much greater need to do it right,” says Dr. Papachristidou, associate pediatrician at the hospital.

Their care is not limited to diagnosis and treatment. They also collect donations of children’s clothing and shoes at their office. Fellow doctors and nurses assist in this endeavor. The two pediatricians also collaborate with the University of Athens and Professor Ioanna Pavlopoulou at the Department of Nursing, pharmaceutical companies, and the hospital pharmacy, to secure a stock of milk and vaccines which are distributed for free to those in need.

Fair access to public health

It is estimated that one in three asylum seekers who arrived in Greece in 2021 was a child. In the 27 countries of the European Union, free health care is a legal right of every child, whether they are documented or undocumented. However, most refugee children do not have access to health care due to their living conditions and the stress of migration. Greece is no exception.

“An unaccompanied minor doesn’t know the health system. He doesn’t have an adult to guide him. He doesn’t know the language. He doesn’t know how to get to the hospital, where to go. We have a specific health system in our country, which is relatively complicated even for the Greeks,” says Dr. Dikalioti.

In an effort to overcome these obstacles, pediatricians are in direct contact with social workers in accommodation facilities for minors in Athens. Most of the tests and vaccinations they perform are free. However, there are many cases where additional examinations are necessary for children who are transferring to a hostel, but these children don’t yet have a social security number. In these cases, the cost is covered by individuals, NGOs and chaperons.

One of the biggest problems they come across is “overuse” of health services. Most refugee children don’t have a health booklet. Thus, exams and medical care performed by other doctors, (especially with unaccompanied minors on the islands), are not recorded. Therefore, there are dozens of cases where chaperons and social workers accompany children to medical screenings which they have already undergone, but they were never officially recorded, because the children don’t have a health booklet.

In addition, medical exams for children who do not yet have a social security number are recorded under a different number, via prosecutor’s order. The files are handwritten and archived using this number. When their social security number is issued – usually four to six months later – any prescription and exam is registered under the new number. Therefore, any previously-recorded history is difficult to detect, even within the same hospital. “Many times we realize that we are examining the same child, just because we remember him from before,” the pediatricians note.

Added to all this is the lack of clear instructions to the patient regarding their doctor’s visit and the documents they must have with him. “Both the staff at the accommodation facilities as well as the doctors have not made it clear to the refugees that they must always have their papers with them. Many children we’ve seen have taken four to five buses to get to their appointment, and they’ve left their documents at home,” said Dr. Dikalioti. That’s why both pediatricians, in their attempt to create order within the chaos, have recorded specific instructions for the patients and their parents, which they distribute after each appointment.

The signs

Scabies, fungal infections and extremely poor oral hygiene are just a few of the many recurring illnesses that doctors treat on a daily basis. These conditions leave visible marks on children’s bodies. It is common practice for both doctors to also check for communicable diseases, even if it is not required for a child to enter an accommodation facility. Tattoos are often an indication to check for other illnesses.

“Before the journey, they get tattoos as a way to identify their bodies in case they die on the way,” says Dr. Dikalioti. “Often makeshift tattoos are done at refugee camps, using the same needle for hundreds of people.”

Scars, cuts, scratches and burn marks from cigarettes also tell their own stories. “In teens, we see a lot of self-harm,” she says. “Usually, children claim to have been injured in quarrels, accidents or disputes with their parents. However, they have a very strong feeling of frustration and they often harm themselves.” For us, these signs are an indication that they need help from a mental health professional.”

The fire at Moria camp in September 2020 still haunts many children, says Dr. Papachristidou. One sign is enough to start a conversation with a child who seems distressed. “Are you sleeping well? How do you feel?” She reports that many children admit they still have nightmares and find it difficult to fall asleep because of what they experienced during the traumatic fire.

Lost in translation

Even when communication is made easier through interpreters, Dr. Dikalioti says they are called upon to address the gap in medical training. “The assessment of what is normal and what is pathological is different for them and for us,” she says. A typical example is congenital genetic diseases due to incest. “The fact that they do not have adequate medical care in their country explains that many things go unnoticed by doctors,” she adds.

There is also a different perception of the disease. “We had a child who was diagnosed with latent tuberculosis, which can be treated in the pediatric population. When we informed him that he had a positive test, he reacted very badly. He left the doctor’s office furious. Three members of his family had died of this disease. To him, it was tantamount to a death sentence. It was a big stigma to him,” says Dr. Papachristidou.

The progress and treatment of their patients is their reward. “Despite the language barrier, they are on the right track: they follow their vaccinations normally, they come to their appointments. They do what they have to do,” she says, and smiles when she mentions that small children, who they look after for months, bring them drawings and sing them children’s songs in Greek.

However, there are many cases where patients’ progress is hampered by adverse living conditions. “We gave medicinal shampoo and soap to an entire family from Afghanistan who had scabies and asked them to wash their clothes at a high temperature. But the problem persisted for weeks,” says Dr. Dikalioti. The family was homeless and living in a temporary shelter. “They washed their clothes by hand. They didn’t have a second pair of socks or shoes.” The doctors intervened and the family was transferred to a hotel, where the bed linen was disinfected daily and their clothes were washed in a washing machine.

Collaboration across borders

Since 2013, the two doctors have seen a change in the composition of the population they treat. Most young patients now come from Afghanistan, Somalia and the Congo, and fewer are from Syria, Iran and Iraq. However, organizing the care for this vulnerable population, both at Greek and European level, has improved only slightly. Medical exams of patients who relocate, for example, to other European countries are rarely translated and transferred.

Recently, the two doctors considered it a given that they would give the medical records of a child with conductive hearing loss to their German colleagues. In Greece, they had already found specialists for the case. They had organized a medical file including detailed information about the patient’s condition, since a new team of doctors would undertake the case after the family relocated to Germany.

“The patient was a 6-year-old boy from Afghanistan who could not hear because he did not have ears. He had some hearing from the bone of his ear, as he had no ear canal. Nevertheless, he had a great desire to communicate and he managed with the sign language and the few words he could say, to communicate with us much more than his mother,” says Dr. Papachristidou. Preparing the patient’s medical file would save the child valuable time, both in his treatment and in his integration. “Many years of normalcy had already been lost. If he had been born in a European country, the damage might not have been completely repaired, but he certainly would have had hearing aids.” An electronic patient record, which other countries already use, might have been a solution, the two doctors say.

When asked what motivates them to persevere in their work, they say: “Every day you realize that these people are only asking for the obvious. It is the right of every child to have access to health care.”

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