20 June 2008 was World Refugee Day. The theme for this year was ‘Refugee Protection’. For Médecins Sans Frontières (MSF), it was a little ironic. In fact, MSF marked the day by placing public messages in major national and regional newspapers, calling for the South African government and the UN High Commission for Refugees (UNHCR) to provide the necessary assistance and legal protection to Zimbabweans guaranteed under international law.

Even before the recent publicised violence erupted, calls for protection went unheard. MSF has been providing basic health care to migrants in central Johannesburg and Musina since December 2007. In the months since then, the Central Methodist Church in central Johannesburg, a shelter for mostly Zimbabweans, was raided by the South African Police Service in January and more recently townships in Gauteng and the Western Cape turned into conflict zones with foreign nationals forced to flee to their nearest police station for safety.

In an opinion piece in The Star newspaper, Jonathan Whittall, humanitarian affairs officer with MSF, wrote that “the current events should not overshadow the need to speak out about the situation in Zimbabwe, and most importantly the need for adequate legal protection for all Zimbabweans: this should include a halt to all deportations.”

For MSF the concern is the lack of access to services, which includes health care. Many do not seek the health care they are entitled to because they fear deportation. When one has legal status and/or feels protected by the authorities, it is far easier to access services. In fact, in Musina, many Zimbabweans are extremely hesitant to even come to MSF mobile clinics, for fear of being apprehended en route to the mobile clinic, and being deported.

The situation at the Central Methodist Church in Johannesburg is not much better as people without legal status rely on MSF for assisted referral to state facilities. Without MSF referral, the outcome is rarely positive. “One elderly woman our teams encountered had a stroke at the church where she is sheltering. She was denied treatment four times before finally being given basic care,” says Whittall.

The acts of violence against foreign nationals highlighted the need for greater access to health care. On 19 May MSF began an emergency intervention in most of the initial places of safety for displaced foreign nationals, and continues providing primary and mental health care at the seven camps, or temporary shelters in Gauteng. In this period MSF has treated 6 000 patients half of whom for respiratory infections. This should not come as a surprise, though.

People sleeping in tents are exposed to winter temperatures of below 10 degrees, every night. During the day the sun is weak and barely dries the cold and damp clothes and blankets strewn over tents. There are latrines, water points and showers for the displaced persons, but having to take a walk to the nearest one after sunset is a risk for health and personal safety reasons.

The state of uncertainty is detrimental to the mental health of the foreign nationals traumatised by the brutal acts of violence as well as the violent displacement from their homes, mostly in South African townships. Living in police stations, churches and community halls came with its own risks, both in terms of physical safety and mental stability. The organised removal to the temporary shelters only worsened matters. This sequence of events was wholly out of the control of those affected. And for many, this came on top of the traumatic events that forced them to leave their country in the first place.

MSF is presently increasing its mental health care in the seven camps in Gauteng, and the existing health facility in Johannesburg. More than 1 400 counselling sessions for individuals and groups have taken place since the outbreak of the violence.

Adrienne Carter is coordinating the counselling for foreign nationals with 12 other MSF counsellors. She expresses concern for the mounting frustration among the communities in the camps: “We are only now beginning to see the actual effects of recent events. Fear as an emotion is very distressing. People are mostly concerned about their future. They have no idea what’s going to happen. They have options, but no choices. Do you go home, where things are very bad and made you leave in the first place, or do you stay, even though you are very terrified of going back to a community that expelled you?”

Adrienne mentions the situation of the displaced Somalis and Ethiopians. “They cannot go home, but to stay means starting all over again. They have nothing. They have lost everything.” Thus, even with refugee status or asylum documentation, displaced foreign nationals are facing an uncertain future, and protection is desperately needed. Answers and options are needed now.