Migration policies versus public health – the ethics of Covid-19 related movement restrictions for asylum seekers in reception centers in Greece in 2020

Background The emergency context of the Covid-19 pandemic necessitated the use of national and international public health measures of unprecedented scale to minimize mortality and morbidity, often in conflict with other principles and rights, such as the autonomy of individuals. Concerns have been voiced that for populations facing precarity, such as migrants, a disproportionate and unfair application of restrictive measures, deficient application of protective measures, and even enforcement of restrictive migration policies under the pretext of the pandemic has occurred. Methods Various principles have been proposed as moral foundations of public health interventions. The author used two public health ethics frameworks to examine the ethical acceptability of movement restrictions on asylum seekers residing in refugee camps in Greece from March 2020 to October 2020. Results Most of the principles described in the frameworks for the ethical application of movement restrictions were not adhered to. Main concerns include that, measures were prolonged despite lack of evidence about their effectiveness to reduce morbidity and mortality, while posing severe and disproportionate burdens for this population. Conclusions An ethically acceptable public health response to Covid-19 is incompatible with certain living conditions of refugees, asylum seekers, and migrants. The question of whether and if so the extent to which the discipline of public health inherently has the role of rectifying existing injustices and social inequalities when these can be convincingly related to health outcomes, is central to the design of public health interventions for these populations. The answer can exemplify the need to address moral and political determinants of health. It is essential for public health professionals to be aware of the moral theorizations that underpin their work, so as to ensure that their policies are aligned with those and to contribute to the debate that shapes these determinants.

evidence about their effectiveness to reduce morbidity and mortality, while posing severe and disproportionate burdens for this population.

Conclusions
An ethically acceptable public health response to Covid-19 is incompatible with certain living conditions of refugees, asylum seekers, and migrants.The question of whether and if so the extent to which the discipline of public health inherently has the role of rectifying existing injustices and social inequalities when these can be convincingly related to health outcomes, is central to the design of public health interventions for these populations.The answer can exemplify the need to address moral and political determinants of health.It is essential for public health professionals to be aware of the moral theorizations that underpin their work, so as to ensure that their policies are aligned with those and to contribute to the debate that shapes these determinants.

Plain Language Summary
In recent years, thousands of individuals have sought asylum in Greece.They are initially geographically restricted and accommodated in reception centers.These centers, or camps, have attracted international criticism due to undignified and harmful living conditions.In 2020, in the beginning of the CoViD-19 pandemic, the Greek government, imposed strict movement restrictions for camp residents in the name of public health.In this study, the author attempts to examine if the public health measures imposed on asylum seekers residing in reception centers in Greece in 2020 were ethically sound, drawing information from scientific articles, legislative acts and reports from a range of institutions.
Public health measures imposed during the pandemic have challenged individual liberties with the aim to protect human lives.However, for vulnerable populations, such as asylum seekers, it is uncertain if certain measures did more good than harm and if they were used to their best interest.Public health interventions are based on trust and should adhere to ethical principles.
Analysis of available evidence using ethics tools seems to be unable to justify the implemented CoViD-19 response policy for asylum seekers in reception centers.Further research, as well as political will, are needed to determine if and how ethical public health policies for migrants are feasible on a national and international level.

Introduction
Migration is an ancient phenomenon, but it is now increasingly recognized as a core determinant of health 1 .In 2020, 281 million people (or 3.6 % of the world population) were living in a country different from the one in which they were born, with many more displaced within their own country 2 .Causes of migration include labor migration, forced migration (that can be due to conflict, persecution, disaster or other reasons), human trafficking, and other forms of modern slavery and climate change related migration.
Migration is historically linked to public health challenges with a prominent ethical dimension.Known ethical challenges of migration health include policies such as mass mandatory screening for infectious diseases upon arrival and entry restrictions and deportation based on medical conditions such as HIV infection, leprosy, and hepatitis C among others.The notion that migrants are carriers of disease is the most powerful myth related to migration and health originating from ancient times, but recent evidence does not support a high risk of transmission to host populations, especially when health care and surveillance services in the destination country are inclusive 1,3 States carry moral and legal obligations to guarantee the right to the highest attainable standard of health, regardless of location and migration status according to multiple human rights norms, arguably containing inclusion in public health policies and preventive care 4 .Nonetheless, governments often enforce exclusionary policies, invoking other concerns such as national security.Indeed, there is an inherent tension between health and migration policy goals, with the former usually aiming for inclusion and the latter for exclusion.
The emergency context of the Covid-19 pandemic necessitated the use of national and international public health measures of unprecedented scale in order to minimize mortality and morbidity and allegedly to protect national security 5 , often in conflict with other principles and rights, such as autonomy.These emergency measures, including international travel controls extended to border closures and internal movement restrictions, that were declared on a global scale due to the Covid-19 pandemic had a profound impact on the mobility of migrants.These measures led to migrants' (including refugees and asylum seekers) inability to flee from their countries of origin, face increased barriers to enter transit or destination countries, or be stranded in places with overcrowded and poor living conditions in transit or destination countries without access to health care and protection.Thus, for many countries, the state of emergency brought by the pandemic took precedence over the central international norms regulating migration, such as the principle of non-refoulement for refugees and asylum seekers, as evidenced by border closures 2 .There are documented occurrences where ethnic and racial groups have been marginalized and portrayed as health threats and socioeconomic disparities along these lines have intensified during the pandemic 6 .Additionally, concerns have been voiced that in populations having precarious legal status, such as migrants, refugees, and asylum seekers, there has been a disproportionate and unfair application of restrictive measures 7,8 , as well as a deficient application of protective measures.Perhaps even more worryingly, some policies have been seen as instrumentalizing public health to achieve migration policy targets 7,9 .In line with recognizing the importance of the moral and political determinants of health 10 , examining the evidence and shedding light on the effectiveness and justice of implemented public health policies can be seen as a moral obligation of (public) health professionals.
In the beginning of 2020 and at the start of the pandemic, approximately 100.000 asylum seekers were estimated to reside in Greece, of which more than 40.000 were located on the North Aegean islands 8,11 .The vast majority of those were living in the Reception and Identification Centers (RICs).These figures do not include persons that have received refugee status or undocumented migrants.Mass quarantine and other restrictive measures were applied for longer periods and to a greater degree to encamped asylum seekers than for the general population with the stated objective of reducing transmission 12 .
At the same time, substandard living conditions, overcrowding inside these camps, and challenges in accessing health care raised questions about the possibility of increased infection and other health risks inside these structures.The RICs were operating several times over capacity and many residents were living in informal areas around the official camps.In July in Moria RIC there were an average of 54 people per toilet and more than 61 per shower, falling well below humanitarian standards, while thousands of people were also living in

Amendments from Version 1
In this new version, several changes have been made to address the reviewers' comments.
Introduction: More information has been provided about the context , including the numbers of asylum seekers on the country and the RICs at the time of the study and a more detailed description of the living conditions in the RICs.A sentence to highlight the consequences of the pandemic on ethnic and racial groups worldwide has been added.Any further responses from the reviewers can be found at the end of the article informal extensions of the camp without formal water and sanitation facilities 13 .Queuing in close proximity was inescapable to access the camp's food distribution and medical provision services, as well as water and sanitation facilities.Access to healthcare was limited due to lack of resources and legal/administrative barriers for migrants.Consequently, the overall effectiveness of the said restrictive measures, as well as their ethical acceptability can be put into question.

Methods
The ethical acceptability of public health interventions that restrict individual liberties , including movement restrictions, has been theorized as justifiable on a number of conditions, such as overall benefit, collective action and efficiency, fairness in the distribution of burdens, prevention of harm, paternalism, least restrictive means, transparency, and various other related (and sometimes overlapping) moral concepts 14,15 .The first objective of this study is to examine the ethical acceptability of movement restrictions on migrants living in reception and identification centers (mainly refugees and asylum seekers) in Greece from March 2020 to October 2020 in comparison to the measures applying to the general population.The second objective is to discuss the relevant ethical considerations that should be taken into account by policy makers when designing public health interventions for these vulnerable populations.

Study design and definitions
This is a public health ethics case study, based on a document review.
Different legal categories of migrants are used in this article, such as asylum seekers and refugees that mainly reflect the need for states to classify migration.It is important to highlight that these categories do not necessarily reflect individual needs or vulnerabilities.
Reception Identification Centers (RICs) or "hotspots" are defined as the six refugee centers at migration entry points in Greece in 2020 (five in the eastern Aegean islands and on the land border with Turkey), designed to process asylum applications.The hotspots "aim to improve coordination of the EU agencies' and national authorities' efforts at the external borders of the EU, in the initial reception, identification, registration and fingerprinting of asylum-seekers and migrants" 16 .
Temporary accommodation sites are defined as the 32 camps in mainland Greece in 2020, designed to "offer temporary accommodation to third-country nationals or stateless individuals who have applied for international protection within the territory of Greece" 17 .
According to Faden & Sebaya, "Public health as a social institution draws its foundational moral legitimacy from the essential and direct role that health plays in human flourishing, whether that role is ultimately understood in terms of maximizing health or of promoting health in order to advance a broad conception of social justice." 14nsequently, for the purposes of this article, the concept of an ethically acceptable public health policy is defined as one that must demonstrate adherence to the maximization of these social goods, and justify any burdens, through a rational and coherent line of moral reasoning.
Ethical frameworks for the evaluation of movement restrictions Two ethical frameworks for public health interventions were used in an examination of the ethical acceptability of movement restrictions implemented for residents of reception and identification centers and refugee mainland camps.
Kass' ethics framework for public health employs six open-ended questions for the ethics analysis of any public health program (not specific to infectious diseases) 18 .It is articulated in the context of the lack of a public health code of ethics, in opposition to a growing body of scientific literature on medical ethics, and is described as "a code to preserve the negative rights of citizens to noninterference" as well as a code to emphasize the affirmative obligations of public health and to reduce certain social inequities.
On the other hand, the ethics-driven policy framework for implementation of movement restrictions in pandemics proposed by Zadey et al. uses 11 unique but related ethical principles (harm, justifiability, proportionality, least restrictive means, utility efficiency, reciprocity, transparency, relevance, equity, accountability, and cost and feasibility) that can then be processed to answerable questions in order to generate 34 policy indicators 19 .This process is equivalent to the "specification" of these general principles in the context of Covid-19 related movement restrictions.These ethical principles were derived from literature preceding the Covid-19 pandemic on movement restrictions for infectious disease outbreaks and other biohazards, such as bioterrorism threats, the 2003 SARS epidemic, the influenza pandemic, the Ebola outbreak response, and WHO guidance for managing ethical issues in infectious disease outbreaks.Here, we are attempting to use this tool additionally for a specific population group, despite its being designed for application at the national level.Following the authors' example, a principle is considered as adhered to if at least half of the indicators are affirmative.
Many of the resources on the ethical dimension of infectious diseases outbreak and response draw upon the Siracusa principles, an established framework for evaluating the appropriateness of limiting certain fundamental human rights in emergency situations, that state that "any limitation of, or derogation from, rights obligations must be lawful, pursue a legitimate aim, be strictly necessary and proportionate, be non-discriminatory, of limited duration and subject to review".

Data collection
Secondary data about the movement restrictions in Greece in 2020 and the assessment of their impact on the health of the general population and refugees, asylum seekers, and migrants was collected from peer-reviewed original research journal articles archived in online databases, national and regional epidemiological surveillance reports, legislation from the Greek government and reports from EU bodies and non-governmental organizations.
The search strategy for this document review included searching the Covid-19 legislation database for all articles from the ministry of migration, through which 151 articles were identified and read for relevant information.A search of the PubMed database was performed for relevant peerreviewed scientific articles (search string -((Greece) AND (Covid) AND (migrants OR migration OR asylum seekers OR refugees OR reception centres OR RIC))).Additionally, a targeted search for reports of EU bodies and NGOs working with migrants in Greece was performed.The strategy was complemented with snowball searching of all identified documents.
Detailed information about the key documents and their sources used in the application of the frameworks is provided in the data availability statement.
Main passages about the regulation describing movement restrictions in RIC Ministerial circular (published 22.03.2020):"…temporary movement restriction from 21/03/2020…of third country citizens residing in Reception and Identification Centres (RIC)…strictly within a perimeter that will be implemented by the Greek Police, according to its operational plan … Daily, from 07.00 to 19.00 representatives of families or groups residing in the RIC will be allowed to move to the nearest urban centre to cover their needs" Ministry of Health Press Briefing of 03.04.2020: "The Ministry of Migration and Asylum and the general secretariat for the reception of asylum seekers had prepared in a timely manner an operational plan with the name "Agnodiki", in the context of preventive measures to protect the population that is being hosted in reception structures, either on the islands, or in mainland Greece, from a series of threats among which some related to health,.."Agnodiki" plan was activated for the first time on 23/03/2020 and this activation pertained exclusively to the RIC on the islands.Its full implementation was completed on the 24/03/2020.With this activation, a preventive, without any present cases or even suspected cases, complete lockdown, was imposed on the units that are located on the islands on health grounds".

Application of the ethics framework proposed by Kass
The ethics framework for public health proposed by Kass was applied to evidence regarding the movement restrictions for refugees, asylum seekers, and migrants residing in reception centers in Greece from March to October 2020 in order to consider the ethical implications of this intervention.

i.
What are the public health goals of the proposed program?
The public health goal of the movement restriction orders was to "take measures against the presentation of cases and the spread of COVID-19 in RICs" taking into consideration "the necessity of measures to protect public health, in order to prevent the spread of Covid-19 in crowded settings such as the RICs" as stated in the government's ministerial circular of 20/03/2020 20 .
Arguably, the ultimate aim of this intervention is the reduction of morbidity and mortality due to Covid-19.It is not explicitly stated for which population the benefit is expected but presumably it refers to residents and workers of the reception centers as well as the general population.
ii How effective is the program in achieving its stated goals?
At the time of the application of the first measures in March 2020, there was a lack of available scientific evidence for the effectiveness of different public health interventions for the reduction of morbidity and mortality due to Covid-19.
As early as June 2020 the European Center for Disease Prevention and Control (ECDC) issued guidance for infection prevention and control reporting that "there is no evidence that quarantining whole camps effectively limits transmission of SARS-CoV-2 in settings of reception and detention, or provides any additional protective effects for the general population, outside those that could be achieved by conventional containment and protection measures" 21 .
Evidence produced after the implementation demonstrated that during the first epidemic wave (spring of 2020) the risk of infection was almost 28 times higher in refugees and asylum seekers residing in the 32 RSs on the Greek mainland compared to the general population (IPR: 27.66; 95% CI: 24.14-31.6) 8.
Nonetheless, there are serious challenges in determining accurately the effectiveness of the program since Greece lacked a testing and contact tracing strategy for residents of reception centers and outbreaks during the period of the first wave were discovered by incidental testing of patients in hospital settings 22 .Additionally, epidemiological surveillance systems were not in place for these settings and migrants might have not reported symptoms to avoid engaging with authorities.Consequently, significant underreporting of cases can be hypothesized, while there is a complete lack of data availability regarding clinical outcomes such as hospitalizations or deaths for migrants, refugees, and asylum seekers 8 .
iii.What are the known or potential burdens of the program?
Burdens to liberty and self-determination are the most transversal burdens of infectious diseaserelated movement restrictions.A relevant underlying consideration is the condition of the space within which people are restricted.Overcrowded settings 23 , and inadequate access to water 12 , sanitation 23,24 , and medical care 8 are associated with an increased risk of adverse health effects, including but not limited to infectious disease outbreaks.
As part of these negative health effects, there is evidence from Greece and other settings that adverse conditions in refugee camps deteriorate the mental health of their inhabitants 25 , including increased rates of psychiatric disorders 26,27 even before Covid-19 related lockdown measures.
Another consequence of the movement restrictions for asylum seekers was the freezing of asylum procedures, leaving people in a state of prolonged administrative detention and limbo (judicial appeals for rejected asylum seekers were also suspended) 9 .The uncertainty about their future was compounded by the reduction of services for education, recreational activities, legal representation, access to essential items, and self-sustenance strategies 12 .
Finally yet importantly, the stricter and longer application of movement restrictions for migrants contributed to their further sociospatial marginalisation and xenophobic rhetoric, intensifying the representation of migrants as carriers of disease 6,28 .
iv. Can burdens be minimized?Are there alternative approaches?
The most notable measure to minimize burdens was the evacuation of a minority of residents that were classified as having comorbidities from camps in April 2020 in an attempt to shield the most vulnerable 29 .
Burdens could be further minimized if the setting of reception centers would allow for the implementation of standard community measures such as physical distancing, hand and respiratory hygiene measures in a setting of decent living conditions, as well as equitable access to testing, treatment, and care for reception center residents 30 .
Notwithstanding and due to the said structural and administrative barriers, physical distancing and risk-containment measures could not be safely implemented, further measures to de-congest and evacuate residents were not implemented 21 . v.
Is the program implemented fairly?
A system of exceptions in the restriction of movement for specific essential functions was applied to the general population by sending an automated message, but this was not tailored to the situation of migrants at reception centers 12 .
A different provision was implemented for residents of RCs, allowing a limited number of "representatives of families or groups to move to nearby urban areas to cover essential needs", only if no recent case of Covid-19 was reported from the camp population.This led to frequent complete mass quarantine of the camps enforced by the police 31 .
Contravening ECDC recommendations and despite the lack of data proving effectiveness, the movement restrictions for migrants were prolonged until 12.10.2020 32.During the summer of 2020, the general population and tourists (of which approximately 7.4 million visited Greece in 2020) could move freely in a context of "low transmission" 12 , indicating another instance of an unequal distribution of burdens, without any scientific or moral justification 12 .Additionally mandatory quarantine upon arrival was implemented until 2023 despite this not implemented to any other foreigner entering Greece from abroad 12 .
Movement restrictions and complete "lockdowns" of migrant camps were envisioned as the equal application of the stay-at-home orders for the migrant population.However, for persons that are forced to live in overcrowded, unhygienic, and harmful conditions just based on their status as migrants, an unfair distribution of burden can be claimed for an uncertain health benefit (or even harm) for this community.This approach can be even further questioned due to a lack of a tailored testing strategy and adequate access to health services that would correspond to the increased risk of infection, in a fair and rational distribution model.
vi.How can the benefits and burdens of the program be fairly balanced?
Despite the highly burdensome nature of the movement restrictions for migrants, public hearings or any kind of consultation with migrant communities were not undertaken in Greece.Additionally, the national Covid-19 helpline was not operative in most languages spoken by migrants.No government in the EU produced risk communications on disease prevention targeting people in refugee camps or informal settlements at that time 33 .

Application of the ethics framework proposed by Zadey et al.
A description of the main characteristics of the movement restrictions imposed on residents of reception centers from March to October 2020 is provided in the analysis of the first framework above.The author's assessment based on the framework proposed by Zadey et al. is presented in Table 1 34 , in comparison with the performance of the indicators for measures that applied to the general population.According to this model, the principles of justifiability, proportionality, least restrictive means, reciprocity, utility-efficiency, transparency, equity, and relevance can be considered as not adhered to for the

Least restrictive means
Is the least restrictive measure applied before other measures severely curbing individual and communal rights?
The number of steps between the least (travel bans) and the most restrictive (national lockdown) measures?
Stepwise approach

Lockdown as first step
Are voluntary restrictions implemented before mandatory restrictions?
Whether sufficient time intervals are given for every restrictive step to show the maximum effect?

Utility Efficiency
Do the probable benefits of the restriction outweigh the probable risks?
Does the analysis of trade-off (e.g., cost-benefit analysis) between loss of livelihood and other losses against deaths averted and cases averted show net positive benefit?

Reciprocity
Is the government reimbursing the individuals for curtailing their rights and for the loss of income/ loss of livelihood due to restrictions?migrants, while more than half of the performance indicators had an affirmative answer for the general population of Greece.

Main findings
We have applied two distinct frameworks to evaluate the ethical acceptability of the movement restrictions imposed upon asylum seekers, refugees, and migrants living in reception centers between March and October 2020.
According to the application of the first framework, this intervention failed to achieve its goals for reduction in morbidity and mortality due to Covid-19 for this population and was prolonged despite lack of evidence about its effectiveness.It posed severe burdens for the physical and mental health of migrants, while increasing stigmatization against them in public discourse.Other public health interventions, such as inter-community protective measures (hygiene and physical distancing) could not be applied in the context of the camps and access to health care was reduced.The movement restrictions were stricter and longer than for the general population, without adequate justification or consultations with migrant communities.No helplines or other procedures for grievances were available.The alternative approach to evacuate the camps was not preferred.Thus, it can be claimed that most of the questions do not have satisfactory answers to consider the movement restrictions, as implemented in this context, ethically acceptable.
Using the author's assessment of the second framework, only 2 out of 11 principles were respected for this population in comparison to 9 out of 11 for the general population of Greece, as evidenced by the performance of derived indicators.Specifically, the principles of justifiability, proportionality, least restrictive means, reciprocity, utility-efficiency, transparency, relevance, and equity were not adhered to vis a vis this public health intervention.
The lack of ethically acceptable policies for encamped migrants in Greece's public health response in 2020 represents a critical flaw in the management of the first period of the pandemic.

Strengths and limitations of the ethical frameworks
The ethical frameworks that were used have different methodologies but can be considered complementary.Kass' framework represents a more qualitative and narrative approach that can encompass the particularities of public health interventions with open-ended questions, while the framework of Zadey et al. is more specialized and attempts a quantitative grading of the ethical acceptability of movement restrictions.Open-ended question based frameworks can be used to grasp and account for broader moral relations and determinants, such as the significance of the structural disadvantage of the position of the asylum seekers in terms of social determinants of health, even prior to the advent of the pandemic.On the other hand, a valuable aspect of the quantitative approach is the ability to compare and contrast different interventions, either between population groups or even between different settings or different points in time.
Ethical frameworks do not represent rigorous or exhaustive scientific tools, have inherent validity limitations and cannot aspire to unequivocally solve ethical dilemmas.Indeed, overlapping questions and ethical principles can be found in the tools that were used in this study.Childress et al. note, "the terrain of public health ethics includes a loose set of general moral considerations -clusters of moral concepts and norms that are variously called values, principles or rules -that are arguably relevant to public health" 15 to which different weighing can be "assigned".Methodologies based on "mid-level" moral principles or "principlist" approaches have been both criticized and defended for not aspiring to the status of a universal moral theory that can prioritize between different moral elements 35 .
A relevant inherent limitation of public health ethics frameworks is associated with the limits and extent of the field of public health itself, as expressed in Kass' question, i.e. to which extent the discipline of public health inherently has the role of rectifying existing injustices and inequalities when these can be convincingly related to health outcomes.The effectiveness of generative frameworks for public health programmes can be constrained by contradicting policies from other fields of governance, which may prioritize different values, such as migration or national security.Balancing between these higher-level considerations is not only usually beyond the influence of the public health professional, but also inconceivable without the use of universal moral theories or political discourses.

Policy and practice implications and conclusions
Despite the existence of different moral approaches and epistemological limitations, the use of ethical frameworks by public health policy makers and independent public health professionals could serve as an aid to analyze the issues at stake, safeguard the ethical soundness, or even advocate for the abolition of programs.
A central issue in the design of public health interventions for migrants is the possible structural tension with migration policy goals.In this light, Kass' question, i.e. to which extent the discipline of public health inherently has the role of rectifying existing injustices and inequalities when these can be convincingly related to health outcomes, acquires a particular significance 18 .
Indeed, health professionals' call to states to improve the social and political determinants of migrants' health and to carefully assess the need for punitive approaches has been reiterated many times in recent global health literature 1,10,36,37 and can be founded upon multiple and heterogeneous moral theorizations.From a deontological perspective, it is unquestionable that the protection of the health of any human being has the legitimacy of a universal law.From a utilitarian perspective, the evidence of the benefits of migrants in high-income countries is mounting, in terms of positive economic effects and lack of harmful effects to the health of host populations 1 .Additionally, the call for equitable inclusion of migrants in public health plans and responses can be viewed as enlightened self-interest in a global reality that continuously generates migration due to war, climate change, and structural inequality.Arguably, protecting migrants' health is also consistent with the four key principles of biomedical ethics (beneficence, non-maleficence, respect for autonomy, justice) and other principles that have been applied to public health interventions, such as the principle of solidarity.
Public health ethics does not only limit its scope to the provision of moral justification of policies and programs, but also aims to critically examine their relationship to one another in a broader context and uncover gaps in relation to a more complete moral picture 14 .Consequently, further research and commitment is needed on how to achieve equitable national and transnational health policies in a world where both migration and transborder health threats seem to be on the rise.What is required as a moral foundation of these policies is nothing less than moral reasoning regarding the equal valuation of lives of citizens and non-citizens on a global level and in the face of states of emergency, despite the reality of political antagonism and diversity of ethical norms.
In this case study and in the context of the Covid-19 pandemic, the evacuation of refugee camps with substandard living conditions, would exemplify a public health intervention that addresses both an urgent health threat and the underlying determinants of health, such as migration policies.Attempts to imitate response measures for the general population, without taking into account the special characteristics and living conditions of this population, can result in policies of questionable effectiveness and morality, which can hardly be categorized under the heading of "health policy".

Rachel Fabi
SUNY Upstate Medical University, Syracuse, USA Thank you for the opportunity to review this manuscript.This paper examines movement restrictions that were placed on asylum seekers living in reception centers in Greece during the early days of the COVID-19 pandemic through two ethical frameworks.The author develops an interesting and useful case study that demonstrates how ethical frameworks might be used to think through public health ethics cases during public health emergencies.I believe this is a valuable addition to the literature on the ethics of public health policies in the context of a pandemic and a thoughtful consideration of the ways migrant rights are often unjustly abrogated for reasons that ostensibly relate to public health but are in fact grounded in xenophobia.
The paper could be improved in several discrete ways that could improve the readability and rigor of the work presented.I will divide my recommendations by section.

Title/Abstract:
As a minor note, the title of the paper doesn't fully work.The migration policies are not being weighed against public health, so "versus" doesn't make a lot of sense here.Perhaps "and" instead of "versus" might better capture what the manuscript seeks to analyze?
I am also a bit confused by some of the text of the abstract.In particular, the "Conclusions" section is worded in a way that is unnecessarily complex, to the point that some meaning may be lost: "The question of whether and if so the extent to which the discipline of public health inherently has the role of rectifying existing injustices and social inequalities when these can be convincingly related to health outcomes, is central to the design of public health interventions for these populations.The answer can exemplify the need to address moral and political determinants of health."-these sentences do not have a clear meaning.
Finally, so much of the abstract is written in the passive voice that it is difficult to understand."Concerns have been voiced," "Various principles have been proposed," "were not adhered to"these points would all benefit from identification of an actor.

Introduction:
The author makes several broad, unsupported, or otherwise controversial claims without sufficient evidence or qualification: "Migration is historically linked to public health challenges with a prominent ethical dimension."What does this mean?This paragraph might also benefit from an additional citation illustrating general issues at the intersection of migration and public health, e. ○ Additionally, the author claims that "states carry moral and legal obligations to guarantee the right to the highest attainable standard of health…".While this is an admirable assertion, it is not an uncontroversial claim, and is rejected by many states, despite the UN's best efforts.This claim could stand some qualification.The citation here (#4) is also formatted oddly in the references.

○
This section also suffers from an overreliance on the passive voice, e.g.: "there are documented occurrences where ethnic and racial groups have been marginalized and portrayed as health threats" -by whom?
The author introduces the idea of "ethical acceptability" in this introduction section but does not define it until the methods section.If the aim of this paper is indeed to examine ethical acceptability, it would be helpful to have this concept more fully explored in the introduction.As written, the reader is left wondering "acceptable to whom?" (and, indeed, even with the definition in the methods section, this concept remains underdeveloped).

Methods:
Because this paper presents a public health case study, it does seem odd to organize it into "Methods" and "Results" as though it were a research paper.I imagine this decision must be due to journal requirements?
The Siracusa Principles require a citation.
The text on page 6, from "Main passages about the regulation describing movement restrictions in RIC" through the following two paragraph of text, seem out of context or insufficiently integrated into the paper.Is the "main passages" text meant to be a heading?And if so, I believe it would improve readability if the text following that heading were introduced and contextualized.
I also think this paper would benefit from a better explanation up front of why the author is using two ethical frameworks, rather than choosing one and digging deeper into the selected option.In the strengths and limitations section, the author notes that the Kass framework is more useful for qualitative and narrative analysis, while Zadey's framework is specialized and enables the "quantitative grading of ethical acceptability of movement restrictions."It would be helpful to clarify this choice in the Methods section.
That said, I'm not sure I fully understand this choice!The Kass framework is not really meant to be used in this way, performing a retrospective analysis of a program or policy that no longer exists, but rather is meant for the prospective comparison of possible interventions.Zadey's framework seems like the much more appropriate and obvious choice for this analysis, and yet the author spends most of the actual writing of this paper answering the questions of the Kass framework (not always appropriately, as discussed below), while the entire Zadey framework is relegated to a table without discussion.

Results:
As mentioned above, it seems odd to refer to the analysis of a policy through a framework as "results," but I believe this may be a limitation of the form.
Steps 1-3 and 5 of the Kass framework are applied well and thoroughly, but Kass steps 4 and 6 are underdeveloped.Specifically, step 4 doesn't really make sense as written because the Kass framework asks prospective questions, and the author contemplates hypothetical responses of ways to minimize burdens that were not, ultimately, employed.This is confusing.Additionally, step 6 is not well-explained.Kass asks whether the benefits and burdens can be fairly balanced, and what this is really asking is whether the procedures for adopting the policy were fair.The author does not sufficiently explain the procedures for implementation.
The Zadey analysis is even more perplexing, however, in that the entire analysis is relegated to a table.It is entirely unclear how the author arrived at the answers to the questions for each ethical principle in the framework, because it is not explained.I believe this paper would be much stronger if, instead of spending time on the Kass framework, the author instead unpacked the answers to each of the Zadey framework's questions, with support/citations (many of which could come from the current Kass section).Given the late stage of this review, however, I suspect this substantial of a requested revision is beyond the scope of what may be possible for the author.I do not believe that such a change is necessary for indexing, and I think the author's points remain valid even with the current dual-framework approach, imperfect though it may be.
I also wish the author had spent more time explaining why they included performance indicators for the general population AND the RICs, instead of focusing solely on the RICs.If this was intended to draw conclusions about the fairness of applying different standards to different populations, which I believe it was, it would be helpful to have that spelled out explicitly.

Discussion:
The second paragraph under "policy and practice implications" is redundant with the last paragraph of the strengths and limitations section.The references to deontological perspectives and utilitarian perspectives are somewhat confusing and do not sufficiently tie back to the previous analysis, so I recommend omitting these sentences.The final phrase ("… which can hardly be categorized under the heading of 'health policy'") doesn't really land and could be omitted.
I hope these comments are received in the spirit in which they are intended -I believe this paper offers valuable insights and a real contribution to the public health ethics literature by demonstrating the application of public health ethics frameworks to a real ethical dilemma.The author is clearly passionate and knowledgeable about the policy under discussion, and I believe consideration of a few changes to the presentation of the case study and analysis will strengthen the value of that contribution.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Partly

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?
No source data required

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: public health ethics; immigration; health policy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Reviewer

Ietza Bojorquez
Department of Population Studies, El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico I thank the author for addressing my previous observations.

My remaining recommendation are:
I suggest adding the study aims and design to the Abstract.

○
Provide a link or reference for "... the Covid-19 legislation database" ○ I replicated the author's search strategy in PubMed and obtained 76 results, some of which are clearly not relevant for this article.I suggest adding the inclusion/exclusion criteria to select scientific articles for analysis, and also the inclusion criteria for legislation articles and reports by NGOs, etc.
○ I suggest the author reviews the phrase "Main passages about the regulation describing movement restrictions in RIC".I understand it was added in response to a previous observation, but I think it's difficult to understand for a reader who is not aware of the

○
The manuscript could be benefitted by a minor revision in terms of the articulation and presentation of the argument, connection between theory and research data.

Introduction
The section introduces the problem and it is informative regarding this particular issue in Greece, but is should be more focused on the Greek context.It could undergo a minor rewriting and include: a) Official data from the Hellenic Ministry of Migration and Asylum (about migrant/asylum seekers/refugees) (https://migration.gov.gr/en/statistika/) and from the National Health Organization (EODY) (https://eody.gov.gr/en/covid-19/) and expand this section.
b) Information about the conditions, capacity at that time and more details on the facilities.c) A better connection with previous works on the topic.For example: Tsavdaroglou (2022) 1.
https://migrationhealth.org/wp-content/uploads/2021/05/lancet-migration-situationalbrief-greece-03-en.pdfd) Provide a point-by-point analysis of the measures implemented during the pandemic that impacted migrants/asylum seekers/refugees in the RICs and Accommodation Facilities in the mainland.

Methods
Methods are appropriate and the fit between theoretical discussion and methodology is well formulated.

Results
The assessment framework is well developed, and aids the author in his analysis, and in framing the findings.The results are of interest for practice, social and migration policy and society more generally.Here a better connection with previous research findings could be implemented.

Discussion
A well-organized and compelling discussion section is provided as well.

Conclusions
A short concluding section could be added.Reviewer Expertise: Sociology, Migration, Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have Third, the results presented are descriptive, followed by a reflection on the importance of applying ethical principles in public health work, especially with vulnerable populations.But there is no joint discussion of the results based in each of the two frameworks (e.g. are they complementary, contradictory?), nor of the usefulness of the moral reasoning behind those frameworks, or the particulars of the frameworks when applied to certain population groups.These are only a few lines of thought that came to my mind when reading this article, and I think they would enrich it and help to move forward the field of public health ethics and practice.
Additionally, I have the following comments:

INTRODUCTION
"States carry moral and legal obligations to guarantee the right to the highest attainable standard of health..." In this paragraph, the author combines moral and legal obligations.
Ideally, the two should align, but this is rarely the case (especially since moral obligations are not frequently the focus of policy/law making).I suggest distinguishing between the two.
○ "Indeed, in our times there is an inherent tension between health and migration policy goals, with the former usually aiming for inclusion and the latter for exclusion" Has there been a time were this was not the case?I don't think so, and even if this is the case, what's the definition (time span) of "our times"?
○ "The ethical acceptability of public health interventions has been theorized as justifiable on a number of conditions, such as overall benefit, collective action and efficiency, fairness in the distribution of burdens, prevention of harm, paternalism, least restrictive means, transparency, and various other related (and sometimes overlapping) moral concepts".But the focus on this article is on the morality of a specific intervention (movement restriction), not on every possible public health intervention.I suggest highlighting the ethical/moral conflicts this specific intervention entails (as opposed to other public health measures), for example the tension between personal/individual liberties and public health goals (refer 2)

George Makris
In this article, the author applies two public health ethics frameworks to the regulations for restriction of movement affecting asylum seekers living in reception centers in Greece during March-October 2020, that were part of the country's response to the COVID-19 pandemic.The author concludes that the restrictions did not conform to the standards for public health action as proposed in the two frameworks.This is an important work, which adds to the discussion of how the pandemic response affected migrants disproportionately, and what concrete steps could be taken to avoid repeating the same errors in the future.It also has the potential to inform broader discussions of public health ethics.
Response: I am very grateful for the detailed, incisive and clearly very informed review, which will definitely lead to the elucidation of many points in the article.
In order to strengthen the article's argument, I identify three major aspects that the author should address: First, the author needs to present the article's objective(s) in a consistent and clear way throughout, and to define the concepts included in that(those) objective(s).In its present form, the Abstract presents the objective as "to examine the acceptability of movement restrictions on asylum seekers".This immediately raises the questions of: what is meant by acceptability? and acceptability for whom? and creates the expectation of a study where migrants and other key informants are asked about their impressions regarding the movement restrictions.Later on, the author seems to use "acceptability" as shorthand for "ethical acceptability", but still it's not clear what is meant by this.Is it "ethical justification", as in Faden & Sebaya (refer 1).Is this the same as "ethical soundness" (p.5).In the Iast paragraph of the Introduction, the main objectives are listed as: "... to examine the ethical acceptability/soundness of movement restrictions on migrants living in camps...", and "to discuss the relevant ethical considerations that should be taken into account by policy makers when designing public health interventions for these vulnerable populations...".After reading the full article, I think the design, methods and results align reasonably well with the first objective, but the second one seems part of the background for the frameworks employed, rather than an actual aim.Also missing is a discussion of the relationship between the two proposed objectives.I suggest the author revises the wording of the objective(s), uses the same terms throughout the article, and defines them.Secondly, I think the author conflates two levels of analysis.From the description of the public health action being analysed (movement restriction), it seems this action was (in principle) developed for the protection of the whole population, and not just those in the reception centers.Therefore, the main analysis should consider if the action conformed with ethical principles at the level of the whole population (the results in Table 1 show it deed).The author makes a very interesting point that they "[attempt] to use [Zadey et al's framework] additionally for a specific population group, despite its being designed for application at the national level analysis" (emphasis mine).What are the implications of doing this?I feel this contradiction is glossed over and not exploited sufficiently for analytical purposes.
Maybe my previous comment is motivated by the limited description in the article of the public health action being analysed.To which action(s)/regulation(s) were the frameworks applied?Was it only "... the government's ministerial circular of 20/03/2020"?or were other circulars included in the analysis?To clarify this, I suggest adding the following to the Methods section: 1) making explicit which regulations or other policy instruments (laws, circulars, protocols, etc.) were considered in the analysis; 2) a more detailed description of the measures included in those regulations/policy instruments (where all restrictions contained in a single document?what did they say exactly? did they change at different times?which ones applied only to the RICs and which ones were more general?);3) a clarification of what were the two frameworks applied to: the written regulations, and/or their actual application?
Response: Different measures for camp residents and the general population I apologize for this point not being clear in the article.In the introduction it is stated that: "Mass quarantine and other restrictive measures were applied for longer periods and to a greater degree to encamped asylum seekers than for the general population with the stated objective of reducing transmission".In fact, two very different, and only to a small degree overlapping, sets of provisions and restrictions (in terms of severity and duration) applied to the general population and residents of reception centres.Therefore, it is justified to apply the frameworks just for the response in reception centers, as to answer the main research question.The comparison with the general population is then used to demonstrate the characteristics of the two approaches.The most important regulations used in the analysis were the ministerial circular of 22/03/2020 and the press briefing of 03/04/2023, which describes the activation of the "Agnodiki" plan on the 23/03/2022.A description of the phrasing of the measures will be added in the Methods section of the revised version.These measures were not changed from then on until October 2020, just extended multiple times.The frameworks were applied to the totality of the evidence collected, including the written regulations, as well as information about their application collected from the sources.For example the first point of the first framework regarding the public health goals is set out in the regulations but the fifth point regarding implementation is answered based on the data regarding implementation.Third, the results presented are descriptive, followed by a reflection on the importance of applying ethical principles in public health work, especially with vulnerable populations.But there is no joint discussion of the results based in each of the two frameworks (e.g. are they complementary, contradictory?), nor of the usefulness of the moral reasoning behind those frameworks, or the particulars of the frameworks when applied to certain population groups.

Response: Frameworks
As mentioned in the discussion, frameworks can be helpful, and even necessary, to ensure that relevant issues are considered by policy makers when a public health intervention is considered.About the two specific frameworks that I used, in the part of Strengths & Limitations, there is a mention of how they can be used as complementary tools, due to their different approaches.At the same time, the broader concern is that any answer based on a framework cannot be considered definitive or exhaustive to endorse an intervention since no framework can be expected to encompass all the nuances of every case.One relevant caveat, which I mention in the Strengths & Limitations paragraph, is that they cannot substitute for a universal moral theory (and do not necessarily aspire to).In this case, the frameworks may give a sufficient answer from a public health perspective, but definitely cannot account for the political and moral elements that shape the final product of the policy maker.In the discussion it is stated that "Public health ethics does not only limit its scope to the provision of moral justification of policies and programs, but also aims to Ideally, the two should align, but this is rarely the case (especially since moral obligations are not frequently the focus of policy/law making).I suggest distinguishing between the two.Response: I am not suggesting that the two are identical.Rather that both can apply as moving forces for promoting migrant health.
"Indeed, in our times there is an inherent tension between health and migration policy goals, with the former usually aiming for inclusion and the latter for exclusion" Has there been a time were this was not the case?I don't think so, and even if this is the case, what's the definition (time span) of "our times"?"The ethical acceptability of public health interventions has been theorized as justifiable on a number of conditions, such as overall benefit, collective action and efficiency, fairness in the distribution of burdens, prevention of harm, paternalism, least restrictive means, transparency, and various other related (and sometimes overlapping) moral concepts".But the focus on this article is on the morality of a specific intervention (movement restriction), not on every possible public health intervention.I suggest highlighting the ethical/moral conflicts this specific intervention entails (as opposed to other public health measures), for example the tension between personal/individual liberties and public health goals (refer 2) Response: Indeed, I am trying to show that as for most burdensome public health interventions that restrict individual liberties, many justifications can be offered, which are all also pertinent in the specific case of movement restrictions.What was the overall analytic strategy?What was the role in the analysis of the different types of documents (policy documents, reports, peer-reviewed literature, etc.)?Were the documents coded for analysis?Was there some sort of validation through multiple coders?

METHODS
Response: Drawing all the information that would be relevant for the application of the ethical frameworks.The documents were not coded for the analysis.
The table under "data availability statement" lists "key documents".Does it mean this were the more important documents, or these were the only ones analyzed?Response: These were the most important documents for the application of the frameworks , the rest are listed as references.
The second section of Methods is titled "Ethical frameworks for the evaluation of movement restrictions".After describing the two that were employed, it mentions the Siracusa principles, making it seem these would be a third framework for the analysis.
: Information on the study design and data collection procedures have been added.A definition of what an ethically intervention means has been included.Two directly translated passages describing the movement restrictions from government sources have been added.Results: Minor additions/editions Discussion: The discussion on the use and limitations of ethical frameworks has been enriched Data Availability Statement: Addition of the press briefing that has been translated in the Methods section.Removal of a redundant source.
g. [Fabi, R. E. (2019).Public health in the context of Migration: Ethics Issues related to immigrants and refugees.The Oxford Handbook of Public Health Ethics, 2019, 244-256].
Report 13 September 2024 https://doi.org/10.21956/wellcomeopenres.25128.r90187© 2024 Fouskas T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Theodoros Fouskas Department of Public Health Policy, School of Public Health, University of West Attica, Athens, Greece The author has sufficiently addressed the reviewers' recommendations in the updated text.Therefore, I have no further comments.Is the work clearly and accurately presented and does it cite the current literature?Partly Is the study design appropriate and is the work technically sound?Partly Are sufficient details of methods and analysis provided to allow replication by others?Partly If applicable, is the statistical analysis and its interpretation appropriate?Partly Are all the source data underlying the results available to ensure full reproducibility?Partly Are the conclusions drawn adequately supported by the results?Partly Competing Interests: No competing interests were disclosed.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.Reviewer Report 13 August 2024 https://doi.org/10.21956/wellcomeopenres.25128.r90188© 2024 Bojorquez I.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

References 1 .
Tsavdaroglou C, Kaika M: Refugees' caring and commoning practices against marginalisation under COVID-19 in Greece.Geographical Research.2022; 60 (2): 232-240 Publisher Full Text 2. Mellou K, Gkolfinopoulou K, Andreopoulou A, Tsekou A, et al.: A COVID-19 outbreak among migrants in a hosting facility in Greece, April 2020.J Infect Prev.2022; 23 (5): 235-238 PubMed Abstract | Publisher Full Text 3. Kousis, M, Chatzidaki, A, Kafetsios, K: Challenging Mobilities in and to the EU during Times of Crises.Springer Nature.2022.Publisher Full Text 4. Sapounas S, Mitrou K, Asimakopoulos AG, Antoniou G, et al.: Impact of COVID-19 Pandemic on Refugees, Migrants and Asylum Seekers Living in Camps and Reception and Identification Centers in Greece in the Pre-Vaccination Period, February 2020 to May 2021.Summary of Epidemiological Findings.Publisher Full Text 5. Dimari, G.: The Emergence of a New Security Apparatus in Greece: The Securitization of the Refugee/Covid-19 Crisis Nexus.PARTECIPAZIONE E CONFLITTO.2021.Publisher Full Text 6. Elhabrouk, Injy: "Crisis Within A Crisis: A Comparative Analysis Of Covid-19's Implications On Greece And Spain's Migrant And Refugee Processing Policies".2020.Reference Source 7. Fouskas, T., Koulierakis, G., Mine, F.-M., Theofilopoulos, A., et al.: Racial and Ethnic Inequalities, Health Disparities and Racism in Times of COVID-19 Pandemic Populism in the EU: Unveiling Anti-Migrant Attitudes, Precarious Living Conditions and Barriers to Integration in Greece.Societies.2022.Publisher Full Text 8. Fouskas, T.: Migrants, asylum seekers and refugees in Greece in the midst of the COVID-19 pandemic.Comparative Cultural Studies -European and Latin American Perspectives,.2020.. Publisher Full Text Is the work clearly and accurately presented and does it cite the current literature?Yes Is the study design appropriate and is the work technically sound?No Are sufficient details of methods and analysis provided to allow replication by others?No If applicable, is the statistical analysis and its interpretation appropriate?Not applicable Are all the source data underlying the results available to ensure full reproducibility?No source data required Are the conclusions drawn adequately supported by the results?Yes Competing Interests: No competing interests were disclosed.
one of the principles of an ethically acceptable programme.I was using acceptability and soundness interchangeably.For clarity, I have changed all mentions to ethical acceptability when referring to the objectives of my study.As mentioned in Faden & Sebaya "Public health as a social institution draws its foundational moral legitimacy from the essential and direct role that health plays in human flourishing, whether that role is ultimately understood in terms of maximizing health or of promoting health in order to advance a broad conception of social justice."Consequently, I use the concept of an ethically acceptable public health policy as one that must demonstrate adherence to the maximization of these social goods through a rational and coherent line of moral reasoning (such as principlism).Regarding the relationship between the two objectives, I believe it is analogous to the two aspects of every case study.The first is to elucidate and to reach a judgment about the specific case and the second is to try to consider the broader determinants of morbidity and try to address those.Specifically, the first objective is addressed by analysing the specific intervention of the state and the second by discussing general concerns (that are triggered by this case) about the interference of migration policies in public health interventions and how this can influence their moral character.
critically examine their relationship to one another in a broader context and uncover gaps in relation to a more complete moral picture" Open question frameworks might be more suited for that purpose to expand on broader moral relations, such as the significance of the already disadvantaged position of asylum seekers in terms of social determinants of health.On the other hand, what I consider valuable in the more quantitative approach of the second framework is the ability to compare and contrast different interventions (between population groups and possibly even in different settings and different times).I am including elements of this response in the revised manuscript.These are only a few lines of thought that came to my mind when reading this article, and I think they would enrich it and help to move forward the field of public health ethics and practice.Additionally, I have the following comments: INTRODUCTION "States carry moral and legal obligations to guarantee the right to the highest attainable standard of health..." In this paragraph, the author combines moral and legal obligations.
Response: What I had in mind is the process of delegitimization of asylum and mistrusting asylum seekers as described by D. Fassin, which describes the declining rates of asylum recognition in Europe from the 1970s in contrast with the years following the Geneva Convention (Fassin, D. Policing Borders, Producing Boundaries.The Governmentality of Immigration in Dark Times.Annu.Rev. Anthropol.40, 213-226 (2011)).Probably the tension is structurally inherent but may be intensified by such processes that influence the perception of asylum seekers.However, this discussion is probably out of the scope of this article, so I will remove the temporal specification from the sentence.
What's the overall study design?Response: Public Health Case StudyThe process for locating and selecting documents for the analysis is not clear.What was the searching protocol?What inclusion/exclusion criteria were employed?What happened if some sources contradicted others?It would be good to have a flow diagram of the document search and search results.Response: The search strategy for this document review included searching the Covid-19 legislation database for all articles from the ministry of migration, through which 151 articles were identified and read for relevant information.A search of the MEDLINE database was performed for relevant scientific articles using the search string ((Greece) AND (covid) AND (migrants OR migration OR asylum seekers OR refugees OR reception centres OR RIC)) Additionally, a targeted search for reports of EU bodies and NGOs working with migrants in Greece was performed.The strategy was complemented with snowball searching of all identified documents.Added the above in the Methods section.

14: The right to the highest attainable. 21.
van de Wiel, W., Castillo-Laborde, C., Francisco Urzúa, I., Fish, M. & Scholte, W. F. Mental health consequences of long-term stays in refugee camps: preliminary evidence from Moria.BMC Public Health 21, 1290 (2021) Scientific Article 3 -Exclusion of migrants from public health communications in Europe Nezafat Maldonado, B. M., Collins, J., Blundell, H. J. & Singh, L. Engaging the vulnerable: A rapid review of public health communication aimed at migrants during the COVID-19 pandemic in Europe.Journal of Migration and Health 1-2, 100004 (2020) Scientific Article 4 -Overview of the CoViD-19 national response and socioeconomic impact in Greece Kousi, T., Mitsi, L.-C. & Simos, J.The Early Stage of COVID-19 Outbreak in Greece: A Review of the National Response and the Socioeconomic Impact.IJERPH 18, 322 (2021).Scientific Article 5 -Comment on EU migration policies and living conditions in camps on the Greek islands in 2020 Orcutt, M. et al.EU migration policies drive health crisis on Greek islands.The Lancet 395, 668-670 (2020) Scientific Article 6-CoViD-19 and living conditions in refugee camps Tsourdi, E. (Lilian).COVID-19, Asylum in the EU, and the Great Expectations of Solidarity.International Journal of Refugee Law 32, 374-380 (2020).Scientific Article 7 -CoViD-19 , xenophobia and racism Petelos, E., Lingri, D., Patestos, D. & Lionis, C. The COVID-19 Pandemic and Refugees in Greece: A New Challenge for Healthcare Service Provision, Public Health Programmes and Policymaking.in Challenging Mobilities in and to the EU during Times of Crises: The Case of Greece (eds.Kousis, M., Chatzidaki, A.

Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests:
The process for locating and selecting documents for the analysis is not clear.What was the searching protocol?What inclusion/exclusion criteria were employed?What happened if some sources contradicted others?It would be good to have a flow diagram of the document search and search results.No competing interests were disclosed. ○