Overcrowding, chaos and a mental health emergency are set to test the E.U.’s resolve over deterring future arrivals by confining asylum seekers to the Greek islands.

The shelter offered to Amira since she got to Europe amounts to a plastic sheet she has slept under for the past ten days. The Syrian mother of three was taken to Vathy, a camp on the Greek island of Samos where nearly 3,000 people are spilling out of a facility built for 700. She struggles to explain to her children, who lost their father in the war, why they must sleep rough being bitten by insects.

“I had protected them until now from the war, but I can no longer protect them here,” said the 32-year-old, who has no diapers for her five-month-old daughter. “It makes me want to scream, but I can’t, not in front of the children.”

October downpours have signaled the coming of winter on Greece’s Aegean Islands and with it the very real prospect of another fiasco to match the frozen misery of last year when six people died. While conditions have improved for asylum seekers on the mainland, the deal between the European Union and Turkey that staunched the flow of refugees and migrants in March 2016 aimed to deter future arrivals by confining them to “hot spot” camps on five Greek islands.

Conditions on these islands have been allowed to fester while the Greek government, local authorities, the E.U. and the U.N. refugee agency, UNHCR, take turns blaming each other. The end of the siege in Raqqa in Syria and in Mosul in Iraq in recent months have pitched severely traumatized refugees, many of them women and children, into the consequences of this neglect.

Amid the confinement, war trauma and overcrowding, a “mental health emergency” is unfolding, Medecins Sans Frontieres (MSF) warned in a new report on October 10. The medical charity recorded a 50 percent rise in mental health cases on Lesbos during July and August, including attempted suicides, self-harm and psychosis.

“The situation on the islands is dramatic,” said MSF’s Louise Roland-Gosselin. “There is no more space in the containers – so people including families have to stay in small camping tents.”

Senior E.U. officials, who oversaw vast funds meant to ensure adequate conditions, know the extent of the overcrowding. The E.U.’s top official in Greece, Maarten Verwey, went to see Spyros Galinos, the mayor of Lesbos, on September 21, seeking his support to relocate asylum seekers from the notorious hot spot at Moria to another facility nearby.

When Galinos refused, Verwey sought to remind the mayor that the E.U. was paying the island’s costs in responding to refugee flows. Local reporters were left to wait outside as the meeting descended into bitter exchanges. No statement was made.

While the refugee crisis has disappeared from daily life in much of Greece, on the islands affected by the geographic restriction there is considerable anger. Islanders complain they are being used as a buffer zone by the rest of Europe and local politicians block the construction of any new camps. On Samos there is staunch opposition even to hotel rooms or apartments being hired to asylum seekers. When staff from a local NGO recently went to inform villagers about plans to offer private accommodation to refugees they were physically assaulted.

New arrivals on the islands are taken to hot spots – facilities that were designed to accommodate people during a short registration process but which now serve as refugee camps, where some people have remained for more than a year. The hot spot on Chios has 1,325 people in a space meant for 894, while Lesbos’s Moria facility hosts 5,000 people despite having a capacity of 2,330.

Since the spring, the Greek government has been taking over services that were previously supplied by international aid agencies and paid for by the E.U.’s humanitarian action agency ECHO. Concerns were voiced at the time over the Greek authorities’ readiness to take over. A letter written to the migration minister Ioannis Mouzalas by staff of the Reception and Identity Service, the agency responsible for running the hot spots, revealed the extent of disarray.

“Interrupting cooperation with NGOs in April was not justifiable,” the employees wrote. “We will not accept one more death [at the hot spots], caused by the weather conditions or the lack [of] adequate shelter and medical support.” They complained that there was “plenty of money from European funds” but that it was not being used. In October, the director of the reception service resigned.

The ministry was not available to comment for this article. It also failed to send a senior representative when Eva Cosse, a researcher with Human Rights Watch, gave a detailed briefing to Greek M.P.s on the situation on the islands in early October. The researcher, who has been visiting Moria since it was set up in 2015, said it was now “out of control” and posed a serious risk to anyone made to stay there. “They cannot pretend they have not been told,” Cosse said of Greek M.P.s.

Agapis Terzidis from the Greek Center for Disease Control, which was meant to hire Greek doctors on behalf of the state to replace the aid agency medical teams, admitted to delays but said that understaffing was not the main problem: “In a place that is made for 2,000 people and holds 6,000, no matter how many doctors you put in service, they won’t be able to make a difference.”

“They cannot pretend they have not been told.”

The U.N. refugee agency, which faced widespread criticism last winter when refugees in Greece were pictured cowering in snow-bound UNHCR tents, has sought to raise the alarm early this year. Philippe Leclerc, UNHCR’s top official in Greece, said the situation on the islands was “approaching critical.”

Fotini Rantsiou, a former U.N. official who now works as a humanitarian consultant on Lesbos, said UNHCR must shoulder some responsibility: “UNHCR is there to fill gaps and it has been given a lot of money to fill them but the gaps are still there.”

In the first year after it came into effect, the deal with Turkey was hailed as a success by E.U. officials and member states and its geographic restrictions did not lead to major overcrowding on the islands. Authorities were able to maintain a precarious balance on the islands as the trickle of new arrivals was matched by departures to the mainland by those granted asylum or judged to be particularly vulnerable cases. Hundreds of asylum seekers were transported off the islands every month.

“Keeping asylum seekers on the islands under these conditions, some for more than a year, is clearly unreasonable.”

This status quo was upended this summer when thousands of refugees began arriving on boats from Turkey. In June, arrivals on the islands surpassed 2,000. By August they had climbed to 3,584 and September saw them reach 4,859. At these levels, U.N. officials warn, the geographic restriction is called into question.

“Keeping asylum seekers on the islands under these conditions, some for more than a year, is clearly unreasonable,” said UNHCR’s Leclerc. “The effects of the geographic restriction must be reviewed.”

Rethinking the terms of last year’s deal would require the Greek government to break ranks with the European Commission, which it has so far been unwilling to do, despite strong support for a change among rank-and-file M.P.s in the ruling party.

MSF’s Roland-Gosselin said it was now a “humanitarian imperative” to challenge the status quo in the Aegean: “The extreme vulnerability of asylum seekers on the islands, and the complete breakdown of systems meant to ensure their reception and the identification of vulnerability, mean that there simply is no other choice than to enable them to move to the mainland.”