The Syrian conflict that began in 2011 has created the biggest displacement crisis since the Second World War, and millions of people are in desperate need of lifesaving humanitarian aid.
Some 4.3 million people have fled the country and an estimated 6.6 million have been internally displaced as government troops, opposition forces and insurgent groups battle for power and control of territory. The complex war has been characterised by extreme violence: civilian areas have been routinely bombed – often in ‘double-tap‘ attacks in which the initial strike is followed by a second on rescue teams or on the healthcare facility receiving the wounded; and there have been attacks resulting in symptoms of exposure to chemical agents. At least 1.5 million people are still trapped in besieged areas without access to humanitarian aid, healthcare or medical evacuation.
The Syrian government continues to deny repeated requests by Médecins Sans Frontières (MSF) to access government-controlled areas. In a country where we should be running some of our largest medical programmes, the opportunities to reach people and to respond in a timely manner to the enormous needs remains extremely limited. This is a forceful reminder of how access to medical care is by and large not respected and is in many cases directly targeted by those involved in the conflict and used for political purposes.
Following the Islamic State (IS) group’s abduction and release of MSF staff in 2014, and the impossibility of obtaining the necessary guarantees from IS leadership that MSF patients and staff will not be taken or harmed, the difficult decision was taken to withdraw from IS-controlled areas. MSF’s activities have consequently been limited to regions controlled by opposition forces, or restricted to cross‐frontline and cross‐border support to medical networks.
In 2015, MSF continued to operate six medical facilities in different locations across northern Syria and saw an increase in the number of people with medical complications caused by delayed medical care, and in infections and deaths due to shortages of antibiotics.
MSF also increased its support programme to around 70 healthcare facilities run by Syrian doctors, with a particular focus on besieged areas. MSF provides technical advice, medical supplies, salaries and fuel, and helps rebuild damaged buildings. MSF also provides ad hoc support to around 80 other medical facilities, such as medical donations for use in emergency situations, for example massive influxes of casualties. No MSF staff are present in these supported facilities.
During 2015, 23 MSF-supported Syrian health staff were killed and 58 wounded. Furthermore, 63 MSF-supported hospitals and clinics were bombed or shelled on 94 separate occasions in 2015; 12 of these facilities were completely destroyed.
In March, MSF released a report highlighting the challenges of delivering aid in Aleppo governorate. The research focused on MSF´s direct experience, but also highlighted the violence suffered by many of the Syrian medical networks and facilities that MSF supports.
The situation deteriorated significantly in Aleppo city in 2015, with targeted attacks on civilian infrastructure such as markets, water supplies and health facilities throughout the year. The intensification of the conflict in Hama and Idlib forced thousands of families to flee to Aleppo governorate.
MSF staff at the 28-bed MSF-run hospital in Azaz district conducted over 32,500 outpatient and 17,000 emergency consultations, and performed 1,200 surgical interventions. The teams also saw 6,000 patients for antenatal, postnatal and family planning consultations and delivered 409 babies.
MSF received reports of attacks on nine health facilities around Aleppo in May, including six hospitals – one was the MSF-supported al Sakhour hospital in Aleppo city, which was forced to suspend activities after being bombed at least twice on consecutive days. In June, MSF had to close its field hospital in Maskan due to ongoing insecurity – the hospital had performed 5,834 outpatient and 2,495 emergency consultations, and assisted 51 deliveries. MSF was able to hand over the hospital´s activities to a Syrian medical network. In August, MSF treated patients with symptoms of exposure to chemical agents in Azaz district.
In early December, convoys carrying essential aid were targeted. This temporarily reduced hospital services and delayed the delivery of emergency supplies, including winter kits containing items such as warm clothes, blankets, torches and soap thadt MSF, in conjunction with Aleppo city council, was delivering to displaced families. More than 7,800 kits were distributed by year’s end.
In March, MSF began supporting the rehabilitation of healthcare systems and infrastructure following the destruction of much of Kobane (Ein Al Arab). MSF built an interim hospital, but the facility was destroyed in an attack in June. MSF supports two urban outpatient health posts, three rural health posts and a small inpatient and emergency room in the town. Routine immunisations were resumed, mass measles vaccinations undertaken and relief items distributed to 4,000 households.
Fighting between armed groups intensified in northeast Syria in 2015. MSF worked in a maternity hospital in the area, where 1,559 births were assisted, including 393 caesarean sections. Regular medical equipment and supplies were also donated. Three MSF clinics provided more than 35,000 outpatient medical consultations to displaced people and the local population, including for chronic conditions and mother and child health.
MSF continued to run the Atmeh burns unit in Idlib, where over 6,800 medical consultations and 5,500 surgical interventions were conducted, and 3,100 patients were enrolled for mental health services. More than 7,000 children were vaccinated against measles and over 3,500 newborns against hepatitis B.
Besieged areas in Homs and Damascus governorates
More than a million people in opposition-controlled neighbourhoods have been under military siege in Damascus and Homs governorates, plus several hundreds of thousands more in Deir ez-Zor and other areas where MSF has not been able to organise support activities. Delivery of official medical supplies from Damascus into these areas is highly restricted; when rare convoys are allowed in, critical items such as surgical materials, antibiotics and therapeutic food are usually removed at checkpoints. Medical evacuations of critically sick patients are hardly ever permitted. Most of these neighbourhoods came under sustained bombing and shelling throughout 2015. On average, more than 300,000 patient consultations were carried out per month in MSF-supported health facilities in besieged areas.
MSF provided medical donations, relief items and technical support to six hospitals and health posts across Dera’a governorate, helping Syrian medical networks undertake 118,000 outpatient consultations, admit 5,800 patients for care and assist more than 2,000 deliveries. These hospitals also treated more than 8,000 victims of violence.
Documentation of the war-wounded
A report compiled by MSF and released in early 2016 showed that 154,647 war-wounded patients were received in 2015 in MSF-supported hospitals and clinics in northwestern, western and central Syria (Aleppo, Homs, Hama, Idlib, Lattakia and Damascus governorates), and 7,009 war dead were documented. Women and children accounted for 30 to 40 per cent of the victims. In 10 documented mass-casualty influxes, such as after the bombings of schools or playgrounds, between 60 and 90 per cent of the victims were women and children.
MSF Doctor – Testimony of a medical practitioner who acts as a hospital director, human resource manager, surgeon and senior doctor in an MSF-supported hospital near Damascus.
“August was the worst we’ve seen [here] medically. Hundreds of injured are coming in. Sometimes we have to go two or three days without sleeping. This month is incomparable to before. It is the worst I’ve seen. We are trying our best. We are trying to save lives and that’s what is keeping us going. We cannot do anything about the siege, it is what it is, and we are just struggling to survive. Of course, I have to hang on to hope. There is always hope.
There is much fear and depression in our community. You see it everywhere. Whenever there is a shelling or the sound of a plane, everyone desperately rushes home or to a shelter. The sound of a plane in the sky is terrifying. It is hard to explain how the situation is on the ground. You have to see it with your own eyes to understand, and even then it is unbelievable. We have seen huge numbers of injured over the past month; in these circumstances anyone who isn’t injured or dead can count themselves lucky.
Medically, we’ve had to become used to the situation, so we do things like rationing of medicine. Rationing has become an important part of our work. We have no choice, so we try to make do with what we have. There are too many patients, too many stories. But one patient shows the madness of this crisis – a child – who I will never forget until I die: he had injuries all over his face, his arms, his legs, and yet he was laughing! Just laughing and laughing. Children usually are afraid of our injections and needles, but he was not. He just laughed, laughed at everything.”