Scabies in Moria

Divya Mishra is an MD-Phd candidate who is currently pursuing her doctorate in International Health at Johns Hopkins. She has previously volunteered in Lesvos and will be working on a scabies awareness campaign with The Unmentionables this summer. 

In November of 2016 I got a message from Ahmed*, a Pakistani migrant in Moria, saying that his friend was very sick. Since Urdu interpreters were scarce in the camp, I had left my contact information with a handful of migrants whom I had worked with during the summer, in case they needed help communicating in an emergency. I called Ahmed, thinking that his friend must be in very serious condition for Ahmed to have contacted me three months after I left Moria.

“There is blood oozing from spots on his back, and he can’t sleep at night because he is itchy,” Ahmed explained in Urdu.

“How long has he had this?” I asked.

“Uh, three, maybe four weeks.”

“Has he seen a doctor?”

“No, not yet. He doesn’t want to go. You know the doctors keep turning people away when they don’t have interpreters.”

How does someone not see a doctor with blood oozing out of their back for 4 weeks, I thought to myself, flabbergasted. I wracked my memory for any disease we covered in medical school that could present with blood oozing blisters on someone’s back.  An autoimmune skin condition, perhaps? Or something infectious?

“Listen,” I began. “you need to convince him to see a doctor. It’s not like he has a cough or cold that will go away on its own. I’ll see if I know any Urdu speakers who are in Moria right now, but he needs to go to the doctors and insist that they take a look at him.”

I did manage to find an Urdu speaking volunteer who agreed to interpret for Ahmed’s friend, and I didn’t hear about him again.

I returned to Moria on January 3rd of the following year. During my first walkthrough of the camp, I stopped in one of the Pakistani sections to see how Ahmed’s friend was doing. The man, Nasir*, stepped out of his tent to greet me along with Ahmed and their other tent-mates. I asked if Nasir had seen a doctor, and if he was feeling better.

Nasir shrugged, looking dejected. “I went to the doctor. They gave me an ointment, but it didn’t help. I went back, and they just gave me the same ointment again, so I stopped going.”

I asked to see the ointment he was given, trying to figure out what his condition might be. It was a broad spectrum antibacterial cream, which didn’t help me narrow down what he might have. I couldn’t actually see the lesions on his skin, as he was fully covered, bundled up against Lesvos’s unusually ruthless winter. I didn’t feel like I had the right to ask him to show me his lesions given that I was not yet a fully trained medical professional, and also a woman, which might make him unnecessarily uncomfortable.

When I discussed Nasir’s case with my roommates later that evening, they insisted that he must have scabies. There was a huge outbreak in Moria, they said, and the warehouse where they volunteered was putting together scabies kits. I honestly hadn’t thought scabies up until that point—scabies typically presents with small rashes connected by a white, threadlike line—burrows of the scabies mite—usually in between fingers and toes, folds in the groin area, and on the legs. Bloody lesions on a person’s back hadn’t made me think of scabies, but it seemed plausible. He had mentioned an itch, and if someone was infected for months, the mites could have spread all over his body, and the bloody lesions could have come from scratching. It wasn’t actually a scenario we had covered in medical school, probably because it would be extremely rare for a person to be infected with scabies for months on end in the United States.

It turned out that my roommates were right. I took Nasir to the municipal hospital in Mytilene in the following days, so that I could interpret for him. He was diagnosed with scabies, given the same ointment he had been given in the camp, probably to treat secondary bacterial infections, as well as a prescription for a scabicidal drug, and a prescription for clothes.

An important part of scabies treatment is the prevention of reinfection after the mites on a person’s body have been killed by the scabicidal drug. Mites can survive for 3 days without human contact, can live on clothes or bedding, on the clothes of household members, and can reinfect the patient being treated. If potentially infected clothes and bedding are packed away for three days and kept away from human contact, the mites die off. However, frequent rain and snow limited the number of dry clothes migrants in Moria had to wear, and Nasir didn’t have enough clothes to wear if he were to pack away all of his clothes for three days.

Unfortunately, the prescription for clothing was not honored at Moria’s primary non-food items NGO. The NGO had a system where only select sections of the camp could pick up supplies on a given day, and Ahmed’s friend would have had to wait until the next week to pick up fresh clothing. Instead of letting Nasir wait a week to get the supplies he needed for scabies treatment, my roommates and I decided to offer him and his tent-mates the scabies kits that were being prepared at the nearby warehouse. We called all four men to meet us at the gates of the camp, as volunteers from the warehouse were not permitted to enter Moria. 

Nasir’s tent-mates were hesitant when we explained to them that they would all have to use fresh clothes and bedding for the next three days. “Well, it’s okay for Nasir,” Ahmed said, “but we’re fine. We don’t need anything.” Nasir had received no counseling from the doctor who examined him about what scabies was, how to prevent reinfection, and what his tent-mates would need to do. Scabies is not a disease that most people encounter unless they are homeless or in very crowded conditions, like Moria, so Nasir and his tent-mates were not aware that they were dealing with a bug infestation for which they all needed to take action. They were convinced that Nasir had some sort of “allergy”. I realized that without understanding what was causing Nasir’s illness, his tent-mates would not be able to rationalize why they, too, needed to be treated.

My roommates and I sat down with Nasir’s tent-mates and explained what scabies was. Nasir looked decidedly comfortable at the idea of bugs living in his clothes, but he didn’t protest. We went through the contents of the warehouse’s scabies kits—a new pair of clothes for 3 consecutive days, including underwear, which many refugees are embarrassed to ask for, and fresh bedding. What we had expected would be a 5-minute stop to drop off supplies ended up being an hour long conversation. However, when I checked in with Nasir two weeks later, he was itch free, after three long months of suffering.

Stories of scabies outbreaks in Greek camps were all over the media that winter. Yet, it wasn’t until I worked with Nasir and his tent-mates to tackle a scabies infestation that I realized the multifaceted challenges of treating scabies in the camps. Limited coordination between medical teams and non-food-items NGOs made it difficult for infected persons to get enough fresh clothes to prevent reinfection during treatment. Since most migrants never encountered scabies before coming to the camps, it was difficult to convince asymptomatic household members that they must also be treated to prevent the disease from spreading. Worst of all, since most migrants did not know the cause of their itch, they were powerless to advocate for themselves and get the supplies they needed to prevent reinfection. Any effort to tackle scabies in camps, I realized, needed to include talking to migrants themselves about the disease in order to be successful.

*pseudonym