Executive

Summary In the last years, a policy -made crisis has been unfolding across Europe, at its borders, and beyond, which has resulted in a surge in deaths, despair and destitution among people attempting to seek safety and protection within the European Union (EU). Across Europe and beyond, Médecins Sans Frontières (MSF) medical and humanitarian teams have been treating the devastating consequences of restrictive migration policies and practices and seen first -hand their human cost.

They have responded in places such as Libya, the Balkans, the Central Mediterranean, Poland, Greece and Italy, which have become laboratories and testing grounds for increasingly harmful policies and practices. This report details findings from MSF medical humanitarian operations in countries in Europe and Africa, as well as in the Central Mediterranean Sea. It takes stock of MSF operational experiences between August and September 2023, drawing upon routine medical and operational data from MSF projects, as well as accounts from MSF patients and medical teams during that period.

The report highlights ho w, at every step of people’s migration journey towards and within the EU, their health, wellbeing and d ignity have systematically been undermined by the interlinking violent policies and practices embedded in EU and EU member state policies.

Key findings: zones of violent deterrence People moving in search of safety and protection, among them thousands of MSF patients, have faced successive and compounding forms of harm, hallmarks of the EU’s intent to trap, block, detain and deny safety to migrants and refugees. ❖ Trapped - People seeking protection predominately from countries in Africa, the Middle East and Asia are violently trapped in non-EU countries without access to healthcare and protection due to EU externalisation deals: • Individuals blocked in Libya, Niger, Tunisia and Serbia are subjected to alarming levels of violence and coercion, including rounds-up, evictions and raids by security forces. • Across Serbia, Niger, and Libya people are pushed into precarious conditions, excluded or unable to access healthcare.

The main issues treated by MSF in these contexts are preventable health conditions, including skin diseases, respiratory infections, and gastrointestinal disorders. • In Libya, people intercepted at sea and returned to detention centres are exposed to grossly dangerous conditions, violence and abuse. People suffer from anxiety, depression, self-harm and suicide attempts.

In Libya and Niger, MSF also responded to people previously intercepted by the Tunisian Coast Guard and subsequently expelled to Libya and Algeria. ❖ Blocked - People crossing the borders of the EU are dying of dehydration, hypothermia and injuries in deserts, forests and mountains while attempting to reach safety or escaping from violent pushbacks.

Others are drowning in the Mediterranean and Aegean Seas due to a lack of assistance and search and rescue and dangerous coastguard practices. • MSF responded to over 28,000 people at EU borders who were injured or harmed due to border walls, pushbacks, lack of search and rescue compounding dangerous journeys.

This included over 20,000 people provided with medical assistance, mental health support, or emergency assistance at EU borders and over 8,000 rescued at sea. • At the Polish border, almost 40% of patients showed injuries reportedly caused by the infrastructure of the border wall. • At the borders of Greece, Bulgaria, Hungary, and Poland MSF treats injuries and harm caused by the violence with which pushback practices were accompanied. • MSF responded to the survivors of twelve shipwrecks off the coast of Italy and Greece, which, together, resulted in up to individuals dead or missing. • Survivors on the Geo Barents reported having attempted the sea crossing from Libya up to times.

Jason Nickerson ❖ Detained - People who manage to cross into the EU face measures that undermine their health and wellbeing on arrival: • Prison-like structures, such as the EU -funded Closed Control Access Centres (CCAC) in Greece, undermine the health of people residing in them.

Depressive disorders, post-traumatic stress disorders (PTSD) and anxiety disorders are prevalent among patients, including children, while preventable contagious skin conditions caused by substandard hygiene and living conditions have been on the rise. • In the hotspots, border procedures generate uncertainty, distress, while the dismantlement of safeguards and assistance result in people being stripped of vital care, protection and assistance. ❖ Denied safety - Meanwhile, those who make it to the shores of Europe are met with exclusionary deterrence policies that deprive them of any possibility to heal, settle and live in dignity. • People denied access to asylum and reception -related rights are left to live on the streets or in squats.

In Belgium and the Netherlands, MSF has responded to a deterioration in people’s health among those excluded from reception-related services. • MSF psychologists have also reported a clear deterioration in the mental health of those living on the streets, with psychotic disorder, PTSD, and depression as main diagnoses. • Children are targeted by state neglect and exclusion. In France, MSF assisted hundreds of unaccompanied minors excluded from state services, care and protection.

Just as violence, in its different and interlinking forms, has cut across contexts where MSF has worked and responded to its consequences, so too does it continue to cut across proposals put forward at national and regional levels in the EU.

The current reforms presented in the EU Pact on Migration and Asylum only further embed a web of violence that aims to deter and exclude those seeking safety. • Dirty deals trapping people in non -EU countries: By enshrining direct financial contributions to non -EU states as a form of EU member state ‘solidarity’, the EU provides an incentive for continued violent externalisation along the lines of what we have seen in Libya, Tunisia, Niger and Serbia. • Violence and non-assistance blocking people at borders: By introducing a new regime allowing member states to derogate from rights, the EU is providing a veil of legitimacy to practices of pushbacks, physical violence and denial of assistance towards people arriving at EU borders, the effects of which MSF has already responded to in Poland and Lithuania. • Detention and denial of care for newly arrived people: By institutionalising the hotspot approach at EU external borders, the EU is entrenching a system based on detention and dismantling protection mechanisms that has already caused widespread harm in countries such as Greece and Italy. • Destitution as deterrence: By predicating reforms on the imperative to halt ‘secondary movements’ and maintain people at the external borders, the EU is institutionalising dynamics that have incentivised the deployment of neglect and exclusion as modes of deterrence, the effects of which we continue to respond to in countries such as France and Belgium.

For years, MSF has been ringing the alarm about the human cost of European migration policies. Despite this, opportunities for meaningful change – represented by the recent negotiations on the EU Pact on Migration and Asylum – have been squandered, further embedding a web of violent practices at the heart of EU migration policy. Faced with this continued normalisation of violence, MSF has no further policy recommendations, quick fixes or simple solutions to propose.

The EU must, instead, urgently confront the issues that lie at the root of this violence, including deep-seated dehumanisation, racism and securitisation of refugees and migrants from non -European countries. This requires an urgent and fundamental change of course, along with meaningful solutions that address the underlying causes, which have, for far too long, resulted in senseless deaths, injuries and long -term trauma among people seeking protection at EU borders.