Refugee Survey Quarterly  51 detention on migrants’ health. However, applying these requirements – which were primarily meant to ensure MSF’s independence of action – has been controversial in practice, especially when acceptance, relevance, and efficacy of MSF activities were put under strain. Acceptance of MSF’s work by the population it intends to assist is fundamental for delivering aid and for ensuring that MSF’s action is in accordance with its social mission. However, acceptance is difficult to obtain when assistance is offered in an incarceration context, which leaves no room for choice to beneficiaries. When MSF is the sole non-governmental actor in a setting run by security personnel, this situation is exacerbated, and during the first interventions of the organisation in Greek detention centres beneficiaries needed to be convinced of MSF’s autonomy. In that effort, it was crucial that the assistance offered was as relevant as possible – meaning that it addressed the needs that beneficiaries consider prevalent. This can again prove challenging for two reasons: 1) the needs most highly prioritised by detained migrants often have to do with protection issues, and primarily the need to enjoy the fundamental human right of personal freedom, which MSF could not address; and 2) MSF placed limits to its own action to protect its perception as an independent actor – and to avoid complicity – which sometimes undermined the relevance of its action. An example of this second point was the reluctance of MSF to repair sanitary infrastructures in detention facilities, fearing that it would shoulder a responsibility that belonged to the authorities. It was a choice that MSF workers on the ground had great difficulty making, and beneficiaries found hard to accept. Some argued that such an action undermined MSF’s independence rather than safeguarded that independence, because it rendered MSF action hostage to the deliberate neglect authorities demonstrated for the needs of detained migrants. As a result of that decision, MSF medical teams had to deal with the health consequences of the deplorable living conditions, while their efforts had a limited impact precisely because neither the authorities nor MSF took action to improve them. In the words of one MSF doctor, [W]hen I first started working in the detention centres, I was shocked by the conditions. Apart from the really limited space in which people are packed, a major problem is sanitary conditions, especially in the latrines, which are in a dreadful state [. . .] Most of the diseases I treat are connected to the[se] detention circumstances.45 Constraints inherent to the detention environment have also been very challenging for the provision of mental health support. Acknowledging that effective provision of psychological aid can only be delivered in a safe and secure environment, which a detention setting cannot ensure, mental health practitioners had to come to terms with significant compromises in their work. In essence, aid workers had to accept that their work was geared towards damage control, as the space for a therapeutic approach was limited. This had a profound impact on aid workers who felt that they 45 MSF doctor working in a Greek immigration detention centre, interviewed in Feb. 2014. See MSF, Invisible Suffering.