Syria Two Years on the Failure of International Aid So Far Final 201303141857

8/21/2019 Syria Two Years on the Failure of International Aid So Far Final 201303141857

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PRESS DOSSIERMarch, 2013

SYRIA TWO YEARS ONTHE FAILURE OF INTERNATIONAL AID SO FAR


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Summary

INTRODUCTION

SYRIA TWO YEARS ON

THE FAILURE OF INTERNATIONAL AID

1 HEALTHCARE IN DANGER

2 CIVILIANS CAUGHT UP

IN THE CYCLE OF VIOLENCE

3 OBSTACLES TO INCREASING AID

FOR SYRIA

4 ASSISTANCE FAILING SYRIAN REFUGEES

5 MSF IN AND AROUND SYRIA


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SYRIA TWO YEARS ON

THE FAILURE OF INTERNATIONAL AID SO FAR

Af w as f an xm n n whh

has sud n m han 70,000 dad adn h

UN, h San a fad wh a humanaan

aash.

Ds ad uss, MSF has n dmssn fm h nmn wk n h

un, bu has bn ab n h hsas n h

sn-hd aas n h nh wh asssan

mans w bw h f h nds.


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1. HEALTHCARE IN DANGERFm ssn a-u dsun

Since the rst protests broke out in Syria in March 2011, the country has spiralled

into all-out war. Violent ghting continues between the national army and oppositiongroups who have gained territory and civilians pay a heavy price.As the conict intensies, health workers and medical facilities continue to receivethreats while medical structures are targeted and destroyed. Here we reect on two

years of conict in Syria, and the mockery made of the concept of medical care in

the country.

Injured people arrested, doctors hunted down

A revolutionary movement shook Syria in early 2011, as in other countries in the Arab world. The

rst major protests took place on 15 March 2011 in Damas. As the weeks wore on, the number ofprotesters multiplied and soon found themselves under re as security forces attempted to quell theuprising. The activists assumed that they could seek care at public or private hospitals should theyneed it, as health structures had the technical means, expertise and resources necessary to treat

trauma. Syrias health care system had once functioned to a high standard. But very quickly thehealth structures were targeted in the campaign of repression.

Accounts from doctors and patients revealed that hospitals were being scrutinised by the securityforces, and that people were being arrested and tortured inside them. Doctors risked being labelledas enemies of the regime for treating the injured, which could lead to their arrest, imprisonment,torture or even death. People injured in protests stopped going to public hospitals for fear of beingtortured, arrested, or refused care, and were essentially forced to entrust their health to clandestinenetworks of medical workers.In Deraa, Homs, Hama, and Damascus, medical care was still provided, out of public view. Makeshifthospitals were set up inside homes near where protests were taking place. Health centres treating

the injured would provide false ofcial diagnoses in order hide that they were treating wounded. Themajor concern for doctors working in these underground networks was their safety.

Healthcare goes underground

As ghting intensied, an increasing number of medical facilities were affected. In July 2011, theSyrian army deployed tanks in the city of Homs; in February 2012, the city was under constant attackby snipers, shelling and aerial bombing by the air force. Aid efforts continued clandestinely; medicsworked as bombs rained down around them. The authorities refused to allow international humani-tarian aid into the country, and a ceasere to evacuate the wounded was also rejected.

A handful of makeshift hospitals were providing healthcare close to the conict zones. They hadbeen set up in caves, individual homes, farms, and even in underground bunkers. Following initialtreatment and stabilisation, patients were transferred to hospitals in safer locations.


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MSF began responding to the conict in Syria by donating drugs and medical supplies to doctors

secretly treating the wounded. In June 2012, MSF set up its rst hospital in the north of Syria, loca-ted along an evacuation route for the wounded. In six days, MSF succeeded in setting up a secretsurgical hospital inside an empty family home. In September 2012, MSF opened two more hospitalsin Aleppo and Idlib provinces, both in northern Syria and controlled by opposition groups.

MSF has not been able to work in government-controlled areas as the Syrian authorities refuse togrant authorisation, despite repeated requests for access. Because of this, MSF can only providedirect assistance and deploy teams in opposition-held territories and can mainly speak of what itsteams see in those locations. The Syrian government is the only side to have an air force and hasbeen targeting health centres in air raids. MSF assesses the security situation of its teams on a dailybasis, and ensures that the hospitals remain demilitarised, neutral spaces.

Health structures targeted and destroyed

The repression of peaceful protests drove the opposition to take up arms from 2012 onward. Whilethe armed opposition gained territory, the conict in Syria took a more violent turn. Medical struc -tures were targeted and destroyed while healthcare workers were threatened or killed. Providingmedical care was transformed into an act of resistance, and medical structures became militarytargets.

In July 2012, a new front opened up in Aleppo. The economic capital of the country was ravaged byaerial bombardments and ground ghting. Buildings, including medical facilities, were decimated;the blood bank supplying the regions hospitals was the rst to go up in smoke.

Dar El Shifa, the largest private hospital in Aleppo, was situated in an opposition-controlled areain the east of the city. It provided care for victims of violence until it was bombed in an air raid inAugust. Although the operating theatre was destroyed, the emergency ward continued to operateand saw about 200 people per day until further bombing completely demolished what was left ofthe hospital at the end of November, rendering it denitively out of service. An emergency wardwas discreetly set up in the neighbourhood to care for the steady ow of wounded. To minimiserisk, medical activities were decentralised into different locations. Two private clinics took on Dar ElShifas caseload; the wounded were brought in on stretchers by people on foot, until one of the twoclinics was also bombed.

Hospitals in Syria are now being used as a tool in the military strategies of the parties to the conict.In liberated areas, some hospitals are being set up or transformed into Free Syrian Army (FSA)hospitals or supporting the Revolution. As a result, these hospitals are at risk of becoming targetsand civilians are rarely accepted.

Opposition military bases have been established close to some makeshift hospitals even in thesame building in some cases. These hospitals are at serious risk of being caught in the middle ofghting or even directly hit in an attack.

According to the Syrian authorities, 57% of public hospitals in the country have been damaged and36% are no longer functional. For a complete picture of the devastation, makeshift hospitals set up

by the opposition and subsequently destroyed by the army must also be added to the tally.


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Difculty in caring for the wounded

As bombing is rife, there is a clear need for trauma surgery and treating the war-wounded hasbecome a priority. However there are great difculties in providing this kind of care.

Drug production and distribution hubs inAleppo have shut down; stocks are virtuallyexhausted. Supply from Damascus is nolonger possible; by and large, the onlyway to bring supplies into Syria is throughunofcial supply routes from neighbouringcountries.

Moreover, the power plants serving theAleppo region have been destroyed.Hospitals are able to run thanks to electricityproduced by generators, but obtaining fuelfor them is very difcult. These facilitiesfunction as well as they can, given theshortage of medical supplies. I saw oneemergency ward where they had no

sterilisation tools. They had to do sutures

with materials that had already been used,says MSF doctor Natalie Roberts, recently

returned from Aleppo.There is also a lack of ambulances totransport the injured to hospital. Patients aretransported on motorbikes and in personalvehicles both of which are generally notequipped to stabilise wounded patients.There are only about a dozen ambulancesin usable condition in all of Aleppo province.Vehicles like ambulances are, of course,also vulnerable to gunre.

The humanitarian emergency in Syria hasmade it necessary for people to take onjobs for which they are not trained. Many

Syrian healthcare workers have ed the country, and those who remain do the best that they areable. Among those who remain are specialists, doctors-in-training and surgeons with no experienceoperating on war-related injuries. Dentists are performing minor surgeries, pharmacists are treatingpatients and young people are volunteering to work as nurses. This is a war, and everyones got todo it all, says one of them.

HoSpitAlS iN DANger

D K s a sun. H ds sua a f h wundd

n a 30-bd a hsa n h nhws f Sa.

A msse anded abu 50 mees fm he

hspa; he wndws wee bwn u. the amyhad been ageng he hspa. ths s he ny

funcnng hspa n hs cy, and as seves 15

he wns and vages a ppuan f 200,000

ey n hs facy. Wee abe wk and hee

ae enugh dcs, bu hees a ack f dugs and

medca suppes. ou scks have un u. rgh nw

we need X-ay ms, exena xas.... we can

d ab anayss hee anyme s pepe have g

esewhee.

the amys psned abu 20 km away fm hee hey k ve he cy wce as yea. When hey

came, i had eave because hey aes dcs wh

ea he wunded. F hem, dcs ae as gd as

ess. they came n he hspa and k a

paen gh fm he wad.

Why d i keep n wh hs? Because f i eave, nbdy

ese w cae f he sck. ive had mupe heas

bu ive managed escape s fa because ive had

fends wh waned me.


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No BlooD BANK

la uans f bd a ndd n d a ans wh n-ad njus. th n bd

bank n h A aa was dmshd n an a ad whn h hn ban, s hsas n h aa

ha bn sun da wh hs dfu suan f mnhs.

Fndn dns s n h bm man a ha bd. th ssu s, kn h bas f

bd . Ms hsas a n ud wh fas. if a fa s funa nuh ha n,

a na s ud k h fd unnn as h s sn n w n h n.

in addn, hsas n h aa d n ha h sn maas ud anas and dmn bd. As a su, wh nd un bd ansfusns a n bd whu h nssa ss

han bn ad u and h nsuns an b faa.

i head abu a pegnan wman wh had gne hspa gve bh,sas D Naa rbs.

She needed a bd ansfusn whch was gven bu he bd used was n he gh ype. She

ded, and s n cea whehe was he haemhage, he ansfusn sef, ha ked he.

MSF has dd a fd, mn f fu, sn sus and ann s u a nw bd bank. ths

nw fa nw sus hsas n h A n. i s s a sk f bmn a ma a.


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2. CIVILIANS CAUGHT UPIN THE CYCLE OF VIOLENCEIn the regions in northern Syria where MSF is working, people have suffered greatloss and devastation. This is especially true in the urban and semi-urban areas that

are bombed indiscriminately and where there are large gatherings of people, suchas markets and bread queues which have been targeted by the air force.

In addition to the physical devastation, the countrys social and economic systemshave broken down, and civilians are the rst to suffer. Despite a massive outpouringof local solidarity, the ongoing conict has brought the healthcare system to its

knees, while living conditions have severely deteriorated. Meanwhile, resources arerunning out and peoples capacity to help each other is being tested.

Civilians terrorised

Since starting work in northern Syria, MSF has

been witnessing how the violence is directlyaffecting civilians. Patients injured by shrapnelor bombs at the market or even in the breadlinemake it to hospital only thanks to the efforts oftheir fellow citizens willing to help each otherdespite the distances to health centres and theconstant threat of bombings.

Some villages are hit by rocket re or have

explosives dropped on them by helicopters on

a daily basis, says Katrin Kisswani, an MSFcoordinator in Syria. This has had a devastating

effect on people. A few days ago, a helicopterdropped a couple of barrels with TNT and bits of

metal inside right in the middle of a village. We

treated the victims in our eld hospital some

of them were women and children. During

exploratory missions, MSF teams have alsocome into contact with people who had beenliving without any outside assistance at all.

Civilians have been traumatised by the conictand live in constant fear of gunre, rocketsand missiles. They are even suspicious of oneanother: sometimes they would not give theirreal names out of fear their stories would becomepublic and their families would be threatened.On 13 January of this year, 20 people were killedand 99 injured after a marketplace was bombedin Azaz. MSF treated 20 of the wounded, all

of them civilians including ve children. Onlytwo days later, a further 44 patients receivedemergency treatment in another MSF facility,after several barrels of explosives were droppedon a village and a rocket landed in Idlib province.


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FeAr oF plANeS

Faum H. 55 as-d, ss usd an MSF hsa af sn h andsn. Sh as h

buzzn f San waans Azaz, a wn n nhn Sa s h tuksh bd, n h

summ f 2012. An ask h h hm, huh n n n h fam was njud as h w n

hm, bu h snd was m dsd. th a h and dbs fm h ma

mand as hsa mnds f h aak.

A fw mnhs a Faums andsn, sx a-d Mhammd, was an a hm wh hs

bhs whn waans w Azaz.

the kds pancked and saed un dwnsas. Mhammed dd n see he he and fe

dwn , bke hs eg and njued hs head, sas h andmh. i wasn an aske, bu

he sund f he panes was enugh fghen he chden and send hem unnng. the by

was eaed a an MSF ed hspa n he egn. Hs gandmhe s eeved bu emembes

hw had was nd medca asssance. We wee d n Azaz ha we had g tukey.

in he end we came hee, and he was admed.

MAN WoUNDeD WAitiNg iN A BreAD qUeUe iN HAlFAyA (Hama n)

one afenn a he end f Decembe, i was wang a he bakey buy bead. thee wee

abu 300 pepe n he ueue s he ny bakey n wn has s pen. id been wang

f hee hus when suddeny a pane ew vehead and w msses h us.

thee was sceamng a aund me many pepe had been wunded. i fe dsened; i fe

as hugh my ps and ngue wee bunng. injued pepe wee aded n vehces. i was

aken a heah cene s n a wheebaw, hen by mcyce ax. i was uncnscus

f hee days. the secnd day, my bhe bugh me anhe medca cene befenay bngng me hee he MSF hspa n a van. thas when hey peaed n me.

im s havng pbems wh my eas hees cnsany a ngng n hem and i can eay

hea. the ncedbe hng s ha my w daughes came away fm kay. A sem-capsed

wa peced hem fm he expsn, s hey ny had a few cus and scapes.

A h MSF hsa, a sun and hs mans wunds and h as f ha had bm

n, and suud h sma us n hs fa. th sz f h wund n hs f shud and h

s f h nju hs h hand man ha h had b ansfd a hsa n tuk

f nsu su, as h MSF fa sn ud a u suh mx dus.


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A health system

in collapseBefore this conict, Syria had a well-functioninghealth system. The country has trained health

workers, medical expertise and a pharmaceuticalindustry. But today resources are depleted.Health networks are breaking down because ofsupply problems and drug shortages resultingfrom the collapse of the pharmaceutical industryor indirectly from international sanctions imposedon Syria.

The intense violence makes accessinghealthcare very difcult. In Homs, Aleppo andin the area around Damascus, snipers presenta constant danger. Moving from one area to theother is often impossible, and entire communitiesare consequently deprived of medical care.In a medical emergency, patients face a grimdilemma: either forgo medical attention or risknding themselves in crossre..

Patients are often sent to under resourced health

facilities, if theyre lucky enough to receive anycare at all. In many hospitals care is rst given tocombatants, but large numbers of patients alsoneed medical attention, be it for chronic illnesses(e.g. diabetes, cardio-vascular diseases, andkidney failure), obstetric care and post-operatorycare, and have difculty accessing care.

Many health facilities have closed because

they lack essential equipment, and others are

concentrating only on trauma. This makes it

that much more difcult for people to accesshealthcare, says Miriam Alia, an MSF medical

coordinator in Syria. In the regions where weve

been working, the children havent received

vaccinations in the last 18 months. Theyre

not protected against contagious diseases like

measles and tuberculosis. Sanitary conditions

are worsening as water is so scarce which also

increases the risk of disease.

Recently there have been reported outbreaks ofthousands of cases of cutaneous leishmaniasisin northern Aleppo province. Local doctors inDeir ez-Zor reported to MSF that 1,200 cases oftyphoid fever, which can be fatal, and 450 casesof cutaneous leishmaniasis had been registeredby the end of February. Drugs for tuberculosishave been unavailable in the region for months.

Diabetic patients require regular treatment andfollow-up but at present they have been left totheir own devices. Without insulin, patients

are coming in with blood sugar levels of up to

5 grammes/litre, and we have had some with

a gangrenous foot that requires amputation,

says Anne-Marie Pegg, an MSF emergencydoctor.

Giving birthin a war-torn country

Prior to the conict, 95% of Syrian women gavebirth with a skilled birth attendant. With thegradual collapse of the health system, this is nolonger an option for most of them. If a pregnantwoman is lucky, she might give birth with thehelp of a midwife or a traditional birth attendant.However women with complicated deliveriesrequiring surgical care have great difculty innding an appropriate facility.On 1 February of this year, a woman gave birth

to twins by Caesarean section at an MSF clinicin northern Syria. The father of the twins saidthey searched for two weeks to nd a hospitalcapable of performing the surgery.In the MSF hospital in Aleppo province, deliveriesclimbed from 56 in November 2012 to 183 inJanuary 2013. MSFs medical teams have seenan abnormally high number of miscarriages andpremature births among their patients, morethan 30 in December and January alone. This isdue to the stress generated by the conict.


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Deteriorating living conditions

Most of the families have ed the village.Theres no gas, electricity, or bread, and the

phone lines are dead. There is nothing to live off,

says a housewife from Idlib province.

The cost of living has increased considerably,and bombing has cut off the supply of water andelectricity in the north of the country. Since thebeginning of December 2012, there has beenno electricity in the eastern part of Aleppo, inAl Bab, and in the entire region up to Kilis. The

price of fuel has risen signicantly and now thatit is winter, conditions are constantly cold and

moist. People are using wood or fuel stoves tokeep warm, which are often the cause of seriousaccidents.

MSFs Elisabeth Jaussaud, who has returnedfrom east Aleppo, says, In Aleppo, everythingthat even resembles an administrative building

has been bombed. Theres no power in Aleppo

save for the generators. The city is littered with

piles of rubble that block the streets so that carsor armoured vehicles cant pass. Rubbish too is

piling up all over the city.

Another issue is the supply of food. Food priceshave increased sharply in the northern provincesof Syria where MSF is present (Latakia, Idlib andAleppo), so there have been major shortages ofour and baby formula. In response, MSF hasdonated baby formula and several tonnes ofour in Idlib and Deir ez-Zor provinces.

Only a few markets are open. Factories are

closed. When food and vegetables are available,

they are too expensive,says a mukhtar or head

of a village, who did not wish to be identied.

Displaced

and isolated peopleAccording to the Ofce of the UN HighCommissioner for Refugees (UNHCR), two anda half million Syrians have been displaced insidethe country since the rst protests broke out twoyears ago. Most of the displaced people are notliving in camps many settle in buildings andpublic places, or are constantly on the move.Living conditions are very poor for the internallydisplaced, while host communities are alsounder strain.

Access to large parts of the country is still verydifcult. As you go south from the Turkishborder, the level of assistance decreases. It isalso difcult for assistance to reach denselypopulated areas and the desert regions in theeast. The food shortages are so acute thatcurrent supply and solidarity networks cannotcope.In areas under government control, such as thewestern parts of Aleppo city, people are living in

enclaves surrounded by the armed opposition. Itis impossible to supply humanitarian assistancefrom Damascus into these areas.

Faced with a situation that is relentlesslyworsening, an increasing number of Syrians areeeing the country. According to the UNHCR,one million Syrians have been either registeredor are waiting to be registered as refugees mainlyin the neighbouring countries of Iraq, Jordan,Lebanon and Turkey. More than 150,000 of

them arrived in February alone.

So far, aid for Syrian refugees has not beensufcient to effectively respond to their basicneeds. Meanwhile, their living conditions havecontinued to worsen through the harsh winterconditions and sub-zero temperatures.


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3. OBSTACLES TO INCREASING AIDFOR SYRIAThere are major obstacles preventing the increase of aid to both government andrebel-held areas. The government is limiting humanitarian aid; because of the

control exercised by Damascus, assistance can hardly be expanded and aid orga-nisations face huge difculties crossing front lines. Meanwhile, in the north of the

country, insecurity caused by ghting and bombing is compounded by political anddiplomatic constraints , seriously limiting the amount of aid.

Control of assistance in government areas

Since 2012, international aid for Syrians inside the country has been mainly deployed from Damascusby the International Committee of the Red Cross (ICRC), UN agencies (including WFP, UNHCR,UNRWA, etc) and about a dozen international NGOs. This assistance is channelled through theSyrian Arab Red Crescent and local organisations, which are authorised by the Syrian governmentto distribute the aid on the ground. Operations are also under the responsibility of the Syrian Vice-

Minister of International Affairs and Expatriates.Though there is currently insufcient humanitarian aid to meet the massive needs, it will be difcult toget more and more effective aid into the country. For one thing, the government is not permittingany more international NGOs to work in government-held territory indeed, MSF has been refusedaccess to these areas, despite several requests. Also, humanitarian aid organisations are requiredto distribute aid through local organisations, who are already operating at full capacity and whosescope of operations is limited geographically.These constraints also signicantly limit the capacity of aid agencies tolerated by Damascus to reachpeople in the opposition-held north of Syria. According to Valerie Amos, UN under-secretary-generalfor humanitarian affairs, other options for aid distribution, like humanitarian operations led from

neighbouring countries, are not currently feasible without government authorisation or a separateUN Security Council resolution.

Aid to rebel-held areas - limited and piecemeal

About a dozen international NGOs are present at the Syrian borders attempting to get aid into thecountrys interior. This aid was rst limited to sending medical supplies for groups of Syrian doctorsworking clandestinely to treat injured people in makeshift hospitals. Some aid has been provided inthe displaced peoples camps along the Turkish border. MSF rst started supporting these doctorsthis way. With the consolidation of territory controlled by the opposition, MSF was able to enter andopen three hospitals in the north of the country. This was done unofcially, as MSF remains forbidden

by Damascus to work in Syrian territory.

Beyond that, most aid for civilians comes from three sources: the Syrian diaspora, countries sym -


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pathising with the opposition (Saudi Arabia, France, Turkey, Qatar), and political and religious

solidarity networks; thereby subject to the political agendas of these actors.

Meanwhile, indiscriminate or targeted bombing considerably limits the amount of aid provided inthe north of Syria. Aid is distributed through local organisations (such as of doctors, businessmen,etc.), armed groups, and civil authorities trying to establish themselves (such as local revolutionarycoordination councils). Narrow areas along the borders are de facto exempt from the bombing. Butthe supply of aid dwindles further inland from the border, such as in the Deir ez-Zor region, which isparticularly neglected.

Another obstacle for the provision of aid is of a political nature. In the north of Syria, internationalaid providers are struggling to nd ways to collaborate efciently with local authorities and Syrianaid networks. One issue is that there are many representatives and leaders. Humanitarian actorsstruggle to gauge the real importance and operational performance of the different representativesthey come across. Futhermore, humanitarian actors distrust them all the more as these persons canbe afliated with different and competing networks (political, military, or religious, for example).

The nal obstacle is administrative. Though neighbouring countries tolerate NGOs engaged incross-border humanitarian operations into Syria, they are not willing to grant them the logistical andadministrative support that comes with ofcial permission. Aside from slowing down the delivery ofaid, this semi-underground status also conicts with the nancing rules for some donors who arereluctant to fund NGOs carrying out cross-border operations.

What makes this even more of a paradox is that the EU, Turkey and almost 130 other countries

recognise the Syrian national coalition as the sole representative of the Syrian people, and providethem with direct nancial and (ofcially non-lethal) military aid. This being the case, its hard to seewhat is stopping Syrias neighbouring countries and these nancial donors from ofcially recognisingand providing nancial support to humanitarian cross-border operations.

Danger of humanitarian operations across frontlines

Although the current set-up is intended to cover all the existing needs in Syria, the national andinternational aid provided beyond areas controlled by Damascus is limited. This is due to the hugedifculty involved in imposing a temporary ceasere, which would be necessary to get material andteams collaborating with the Syrian Red Crescent safely across the front lines. A spokesperson for

the ICRC who was recently in the country summed it up in a recent public statement: Mountingcross-line operations is challenging, not least because as in every conict neither side is keen

to see us crossing into the area held by their enemy. Armed rebel groups, meanwhile, show greatmistrust towards the Syrian Red Crescent, which is perceived as pro-governmental despite thededication of its members (since the beginning of the conict, seven Red Crescent volunteers andeight UN employees have been killed on-mission).

To cover the needs of civilians, the capacity of humanitarian actors to provide impartial aid on thewhole Syrian territory must be increased and cross-border operations must be facilitated, as a matterof urgency.


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Insufcient aid

At the end of January 2013, more than 60 countries committed to providing more than 1.5 billiondollars in humanitarian aid for the Syrian population. This amount, meant to cover urgent humanitarianneeds for the rst half of this year, can be contrasted with the small sum that the UN Ofce for theCoordination of Humanitarian Affairs (UNOCHA) was actually able to obtain to cover its action planin 2012.

The plan for 2013 includes a regional response for refugees, estimated at $1 billion US for 1.1 mil-lion people, and another estimated at $520 million US for 4 million people directly or indirectly affec-ted by the current events inside Syria. Yet, as of 19 February, the UN action plan had only received20% of the necessary nancing.

This aside, the difference between the amount of nancing for aid going to refugees and the amountallocated to Syrians inside the country illustrates that the current system is unable to respond to thecurrent emergency inside Syria.


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4. ASSISTANCE FAILINGSYRIAN REFUGEESAccording to ofcial estimates, 1 million Syrian refugees are registered or awaitingregistration in Syrias neighbouring countries - Lebanon, Jordan, Turkey and Iraq.But their actual number could be much higher as many people are not in the

process to be registered as refugees. In the past months as many as 7,000 people

have been eeing Syria each day. Most of them are reported to be women andchildren.

The situation of the refugees eeing Syriaemphasises the failure of the international aidsystem to respond to the Syrian crisis. Althoughaccess and security in the neighbouring countriesare not a major problem, the international aidsystem has failed at anticipating and respondingto the growing needs of the refugees. The

massive inux of refugees pouring into Syriasneighbouring countries is weakening furtheralready fragile refugee reception set-ups andworsening the already dire situation of scatteredrefugees in Lebanon.

In Jordan and in Iraq the living conditions inthe refugee camps are grim. The camps aresaturated and hygiene is poor, due to shortagesof latrines and showers. People are living incrowded and unheated tents that offer littleprotection against the bitter winter. Earlier thisyear rainstorms and snow have plunged somecamps into no refuge.

In Lebanon where there are no ofcial campsfor Syrian refugees, an increasing number ofpeople live in inadequate collective shelters,farms, garages, unnished buildings and oldschools. According to a survey conducted byMSF in December, 50% of the Syrian refugees inLebanon are not receiving the required medicaltreatment because they cannot afford it. Food

also is a growing issue. MSF teams have seencases of women having to feed their babies withtea because they could not afford to buy milk.

Psychological distress is widespread amongthe refugees whether they are men, women orchildren. Most of the refugees interviewed byMSF in Lebanon and Iraq reported they edSyria because of the insecurity but also becauseof the deterioration of their living conditions in

Syria (shortages of food, water and fuel and lackof access to medical care).

Thousands of Syrian refugees face anunacceptable situation. After eeing a war zoneand leaving everything behind them, people stillhave to wait weeks or even months before theyare ofcially registered as refugees and receivea much needed assistance. Many families areliving in dire conditions with very little assistance,while others simply not getting any aid at all:roughly one in four of the registered refugeesinterviewed in Lebanon said they had notreceived any assistance, while 65% said theyhad received only partial assistance that did notcover the families needs.

For Iraq, Jordan, Lebanon and Turkey, whichhost nearly all the Syrian refugees, the costtoday is growing and the host populations whohave been very welcoming over the past twoyears are no longer able to carry this burden.Despite the solidarity and the tremendous

efforts of these countries to cope with the crisis,the various aid structures and schemes put inplace are today dysfunctional and will most likely


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remain so if the inux of refugees continues.

A late recognition of the magnitude and durationof the crisis and the ever growing numbers ofrefugees are the main reasons that explainthe delays in the deployment of a responsecommensurate with the needs. But the levelof assistance to the Syrian refugees must beurgently increased today in order to avoid afull blown humanitarian crisis. There must bea more expansive, concerted, and effectivehumanitarian response to provide these peoplewith a relief from the conict plaguing Syria,and ensure that their humanitarian and medical

needs are met.

Since 2011 MSF has expanded its work withSyrian refugees in Lebanon, Jordan, Iraq andTurkey.

In LebanonOut of 300,000 Syrian refugees ofciallyregistered today in Lebanon according to the

UNHCR , 220,000 have crossed the bordersince October. Large numbers of familiesare living in unnished buildings, garages,warehouses and encampments which areutterly unsuitable to face the hardship of thewinter. The main identied needs - in studiesconducted by MSF in December 2012 - areprimarily accommodation, food, winterisationitems, primary and secondary health care, andmental health care. The Lebanese communityhas made a huge effort to assist the refugees.

Though the situation in Lebanon remainsrelatively stable, the economic, social and

political spillover of the war in Syria is having animpact over Lebanon, exacerbating sectariantensions in impoverished neighborhoods ofTripoli. The Lebanese government has statedthat it has no longer the means to face theburden of the refugees alone, and has askedthe international community for support.

In JordanOver 240,000 Syrians refugees are registered orawaiting registration in Jordan. There are now

25 ofcial reception points for refugees along

the border, and many more unofcial crossingpoints. Some 40,000 Syrian refugees crossedthe border in January alone. Zaatari camp, nearthe Syrian border, is now home to more than

60,000 refugees. The living conditions are totallyinadequate. Hygiene conditions are poor dueto a severe shortage of latrines and showers.This winter has been particularly harsh andZaatari camp was partially oodedin January.Authorities have begun to relocate residents toprefabricated bungalows but most are still livingin unheated tents that offer little protection fromthe elements.

In IraqThe Kurdish Region Government (KRG) ishosting the Kurdish population that has edSyria, whilst the central government in Baghdadhas opened two camps in the south-westernpart of Iraq (Al-Qaim and Al Waleed camps).According to the UNHCR, as of mid February2013, there were 96,270 refugees in Iraq

including over 75,500 in the Kurdish Region.

- Domeez camp was established in Duhokprovince in April 2012 and is managed by theUNHCR and the KRG authorities. Initiallydesigned to host 1000 families, the camp is nowhome to more than 50,000 people. Water andsanitation services are poor. The difcult livingconditions for refugees are compounded by thewinter weather and sub-zero temperatures.

- Al Qaim border crossing, the only ofcial bordercrossing for a distance of 400km, remainsclosed. Although some of the sick or woundedare allowed to cross the border to seekingmedical assistance, MSF is concerned aboutthe fate of people eeing the ongoing ghting inDeir Al Zoyr in Syria, who are unable to reachsafety in Iraq.

In Turkey

In Turkey, the refugee camps are managedby the Turkish authorities with the support oflocal actors such as the Turkish Red Crescent.


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According to the Turkish authorities, 183,540

Syrians have sought refuge in seven provincesand are hosted in 14 camps that are all nearlyat capacity. Estimated gures of unregisteredpeople range from 70,000 to 100,000 people.In Kilis the estimated gures of both registeredand unregistered Syrians inside and outsidethe camp are around 40,000. New camps are

being opened but they cannot cope with the

massive inux of refugees. Many people remainstuck at the Syrian border in so called transitcamps, waiting to be transferred to the camps.In addition, many of them try to cross by theirown, settling in Kilis and surrounding areas,sometimes as a rst step in their exodus.

trAppeD By WAr, tHey eScApeD AND tHey SUrvive

tesmnes f Syan efugees lebann

leBANoN Afe a whe hey saed bmbng he wns and vages the amysen anks demsh my

huse. they bke dwn he was and eneed wh he anks hugh he cumns. Nhng was ef

f u huse. We ed anhe vage, bu hee we wee caugh by heavy sheng, s i k he

chden wh wee eed f he bmbs and bugh hem Aasa n lebann , ad a fahef

egh u eams.

400 bmbs wee fang pe hu . We cud n cpe wh he suan anyme, we have chden.We had seep unde ees, n a cave (g), n a vaey hde fm he bmbs. Fnay we had n

he chce han ee lebann pec u chden and u ves.

irAqi aved fm Sya fu days ag. ou ecnmc suan hee was eay bad. We came fm

qamsh, whee hee s n gas, n eeccy, n wae, hee s nhng. the cy s cmpeey

beseged. We ddn have any fue f he heaes s we had use ssues and whaeve maeas

we cud nd. the chden g because f he smke, hey suffeed fm espay an.ths s why we came hee. the p was eay dfcu and vey ng, sad a wman wh ad

wh h husband and un hdn. th fam s s wan f a sh.


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5. MSF IN ANDAROUND SYRIAPrior to the Syria uprising, MSF was working in Damascus providing health carefor migrants. However, this project was closed in April 2011. Then MSF repeatedly

requested ofcial access from the Syrian government in Damascus to be able toprovide assistance based on needs, wherever those needs may be. But so far MSF

has been denied the ability to work in Damascus and in areas controlled by thegovernment.

Initially MSF started supporting groups of Syrian doctors who were treating the wounded by sup-plying them with medicines and medical material. MSF re-entered the rebel held areas of the countryunofcially in mid 2012 but were unable to enter government held areas. MSF now has three eldhospitals in in northern Syria and which the Syrian authorities have been informed of. Whilst ini-tially MSF focused on providing emergency and surgical care, activities have extended to includeprimary health care consultations, maternal care, organising vaccination campaigns against polioand measles. MSF alsoprovide donations of treatments for cutaneous leishmaniasis;communicable

diseases, such as typhoid and chronic illnesses such as asthma, diabetes and cardio-vascular di-seases.

In Syria, over 1500 surgical procedures and over 20,800 out-patient and emergency consultationshave been carried out by MSF teams between June 2012 until the end of February 2013. Many pa-tients come for violence-related injuries such as gunshot wounds, shrapnel wounds, open fractures,and injuries due to explosions. The admission of the wounded is irregular, depending on shiftingfrontlines and whether it is possible to refer patients.

Several other health facilities have been set up by Syrian doctors and other medical organizationsto treat the wounded in the northern region. However, general access to health services remains

limited for the population, particularly for people suffering from chronic illnesses. A signicant num-ber of MSFs patients need treatment for chronic disease, accidental trauma, or assistance duringchildbirth.

MSF is also providing training in mass casualty management, triage, and emergency care to Syrianhealth personnel who need support in the management of war-wounded patients. Specic assis-tance is also being provided to medical facilities, such as setting up a blood bank in a health structurein Aleppo area.Our teams regularly carry out adhoc distribution of relief items including baby milk and our for affec-ted families and donations of medical material and medicine to other medical centres. Throughout

2012 we dispatched several tons of medical supplies and relief items to eld hospitals and clinics inSyria, including into government controlled areas.


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Extending assistance for refugees in neighbouring countries

MSF started supporting local initiatives to help refugees in Turkey in August 2011, and has since thenincreased its activities to include assistance to refugees in Lebanon, Iraq and Jordan. From the startof 2012 until January 2013, MSF has provided nearly 69,000 medical and mental health consulta -tions to refugees in these four countries, mainly in Lebanon and Iraq.

In Lebanon, MSF is assisting Syrians through primary health care services, treatment of chronicdiseases, antenatal care services, and mental health care, as well as distributing relief items. MSF iscurrently operating in Tripoli, North Lebanon, where thelargest number of Syrian refugees is staying,as well as in the Bekaa valley, which is the main crossing point for people eeing Syria.

In Iraq, MSF is the main healthcare provider in Domeez refugee camp where more than 50,000

people have settled. MSF is providing general health and mental health consultations, and immuni-zation and carrying out targeted distributions of hygiene kits as well as improving safe water suppliesand efcient sanitation. MSF is also working in Al Qaim supporting the border clinic run by the IraqiMinistry of Health and in recently started providing mental health services in two refugee camps inthe area.

In Jordan MSF provides reconstructive surgery to war wounded refugees. Currently, Syrian surgicalcases (mainly orthopaedic) represent 40% of the new admissions in MSF hospital in Amman, wherethey are offered physiotherapy, psychosocial support and post-operative care. MSF also runs out-patient consultations for Syrians from the Amman hospital.

In Turkey MSF is providing mental health support in partnership with Helsinki Citizens Assemblyorganization to the Syrian refugees living inside and outside camps, and has distributed relief itemsfor refugee families living outside the camps and who are not helped by the existing aid system.


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OVERALL FIGURES - UP TO 28 FEBRUARY 2013

BUDget: tHe totAl For MSF operAtioNS iN AND AroUND SyriA iN

2013 iS oF: 19 mnA u fundng f pgammes n and aund Sya cmes fm pvae dnans.

HUMAN reSoUrceS (locAl AND iNterNAtioNAl teAMS)

Sa: 229

tuk: 58 (nuds su and dnan f Sa)

lbann: 118

ia: 75 (f fu ams, n nudn ams wkn n h js n ia)

Jdan: 64 (f fu am, n nudn h Amman Hsa j)

totAl : 544 ams mmbs wkn n and aund Sa

MeDicAl ActivitieS WitHiN SyriA (Aleppo AND iDliB goverNorAteS)

UNtil FeBrUAry 2013

1560 sua asw ad u b MSF n h hsas n Sa, ms f n

ad njus.

o 20,800 mda nsuans w ad u, nudn ma haha nsuans

and mn nsuans.

368 babs w dd, ms n h man wad n A, fm Nmb 2012

Janua 2013.

DiStriBUtioNS iN SyriA

o 166 ns f maa w dd nudn ks f an wundd, f an buns,

sua ks and dnans f mda umn suh as xn xas, ansfusn

ks, . in addn hs, 4,000 amns f hd and 500 amns f uanus

shmanass w dd n Fbua 2013 n D ezz na.

rf ms nudn wha u ha bn dsbud n D ezz and idb nas,

and 7500 n n ans ams nx h tuksh bd n A na.


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MeDicAl ActivitieS AroUND SyriA

cnsuans f fus (ouan, mna hah, s fw u)

lbann: uan and mna hah 25250

ia mda nsuans 40000

tuk nddua mna hah nsuans 623

Jdan uan nsuans 2653

Jdan s a fw u 201

totAl opD / MeNtAl HeAltH 68727

in addn hs, n Jdan 190 ans undwn su n MSFs nsu su

amm n Amman and 125 ans w dd wh hsha h

fm h injus.

DiStriBUtioNS AroUND SyriA

Na 55,000 f ms ha bn dsbud n lbann fus wh d Sa. Sn

md Janua u ams ha as dsbud fu 3000 fu uhs 500 fams n h

Bkaa a.

tad dsbuns f f ms (banks, hn ks) ha as bn ad u n ia.

in tuk, Nn Fd ims (banks, hn ks, ss, haa) w dsbud na

6900 San fus wh w n n n h ams and wh had n us d

Syria Two Years on the Failure of International Aid So Far Final 201303141857

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