preSS doSSier

March, 2013

Syria two yearS on

the failure of international aid So far

Photo : Brigitte Breuillac / MSF

Syria report

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

Syria report

Syria two yearS on the failure of international aid So far

After two years of an extremely violent conflict which has resulted in more than 70,000 dead according to the UN, the Syrian people are faced with a humanitarian catastrophe. Despite repeated requests, MSF has not received permission from the government to work in the country, but has been able to open three hospitals in the opposition-held areas in the north where assistance remains well below the level of the needs.

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1. healthcare in danger
From repression to all-out destruction
Since the first protests broke out in Syria in March 2011, the country has spiralled into all-out war. Violent fighting continues between the national army and opposition groups who have gained territory and civilians pay a heavy price. As the conflict intensifies, health workers and medical facilities continue to receive threats while medical structures are targeted and destroyed. Here we reflect on two years of conflict in Syria, and the mockery made of the concept of medical care in the country.

A revolutionary movement shook Syria in early 2011, as in other countries in the Arab world. The first major protests took place on 15 March 2011 in Damas. As the weeks wore on, the number of protesters multiplied and soon found themselves under fire as security forces attempted to quell the uprising. The activists assumed that they could seek care at public or private hospitals should they need 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 the health structures were targeted in the campaign of repression. Accounts from doctors and patients revealed that hospitals were being scrutinised by the security forces, and that people were being arrested and tortured inside them. Doctors risked being labelled as 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 being tortured, arrested, or refused care, and were essentially forced to entrust their health to clandestine networks of medical workers. In Deraa, Homs, Hama, and Damascus, medical care was still provided, out of public view. Makeshift hospitals were set up inside homes near where protests were taking place. Health centres treating the injured would provide false official diagnoses in order hide that they were treating wounded. The major concern for doctors working in these underground networks was their safety.

Injured people arrested, doctors hunted down

As fighting intensified, an increasing number of medical facilities were affected. In July 2011, the Syrian army deployed tanks in the city of Homs; in February 2012, the city was under constant attack by snipers, shelling and aerial bombing by the air force. Aid efforts continued clandestinely; medics worked as bombs rained down around them. The authorities refused to allow international humanitarian aid into the country, and a ceasefire to evacuate the wounded was also rejected. A handful of makeshift hospitals were providing healthcare close to the conflict zones. They had been set up in caves, individual homes, farms, and even in underground bunkers. Following initial treatment and stabilisation, patients were transferred to hospitals in safer locations.

Healthcare goes underground

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MSF began responding to the conflict in Syria by donating drugs and medical supplies to doctors secretly treating the wounded. In June 2012, MSF set up its first hospital in the north of Syria, located along an evacuation route for the wounded. In six days, MSF succeeded in setting up a secret surgical hospital inside an empty family home. In September 2012, MSF opened two more hospitals in 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 to grant authorisation, despite repeated requests for access. Because of this, MSF can only provide direct assistance and deploy teams in opposition-held territories and can mainly speak of what its teams see in those locations. The Syrian government is the only side to have an air force and has been targeting health centres in air raids. MSF assesses the security situation of its teams on a daily basis, and ensures that the hospitals remain demilitarised, neutral spaces.

The repression of peaceful protests drove the opposition to take up arms from 2012 onward. While the armed opposition gained territory, the conflict in Syria took a more violent turn. Medical structures were targeted and destroyed while healthcare workers were threatened or killed. Providing medical care was transformed into an act of resistance, and medical structures became military targets. In July 2012, a new front opened up in Aleppo. The economic capital of the country was ravaged by aerial bombardments and ground fighting. Buildings, including medical facilities, were decimated; the blood bank supplying the regions hospitals was the first to go up in smoke. Dar El Shifa, the largest private hospital in Aleppo, was situated in an opposition-controlled area in the east of the city. It provided care for victims of violence until it was bombed in an air raid in August. Although the operating theatre was destroyed, the emergency ward continued to operate and saw about 200 people per day until further bombing completely demolished what was left of the hospital at the end of November, rendering it definitively out of service. An emergency ward was discreetly set up in the neighbourhood to care for the steady flow of wounded. To minimise risk, medical activities were decentralised into different locations. Two private clinics took on Dar El Shifas caseload; the wounded were brought in on stretchers by people on foot, until one of the two clinics was also bombed. Hospitals in Syria are now being used as a tool in the military strategies of the parties to the conflict. 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 targets and civilians are rarely accepted. Opposition military bases have been established close to some makeshift hospitals even in the same building in some cases. These hospitals are at serious risk of being caught in the middle of fighting or even directly hit in an attack. According to the Syrian authorities, 57% of public hospitals in the country have been damaged and 36% 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.

Health structures targeted and destroyed

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

Difficulty in caring for the wounded

HoSpitAlS iN DANger
Dr K is a surgeon. He provides surgical care for the wounded in a 30-bed private hospital in the northwest of Syria.

A missile landed about 50 metres from the hospital; the windows were blown out. the army had been targeting the hospital. this is the only functioning hospital in this city, and it also serves 15 other towns and villages a population of 200,000 rely on this facility. Were able to work and there are enough doctors, but theres a lack of drugs and medical supplies. our stocks have run out. right now we need X-ray films, external fixators.... we cant do lab analysis here anymore so people have to go elsewhere. the armys positioned about 20 km away from here they took over the city twice last year. When they came, i had to leave because they arrest doctors who treat the wounded. For them, doctors are as good as terrorists. they came into the hospital and took a patient right from the ward. Why do i keep on with this? Because if i leave, nobody else will care for the sick. ive had multiple threats but ive managed to escape so far because ive had friends who warned me.

Drug production and distribution hubs in Aleppo have shut down; stocks are virtually exhausted. Supply from Damascus is no longer possible; by and large, the only way to bring supplies into Syria is through unofficial supply routes from neighbouring countries. Moreover, the power plants serving the Aleppo region have been destroyed. Hospitals are able to run thanks to electricity produced by generators, but obtaining fuel for them is very difficult. These facilities function as well as they can, given the shortage of medical supplies. I saw one emergency 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 to transport the injured to hospital. Patients are transported on motorbikes and in personal vehicles both of which are generally not equipped to stabilise wounded patients. There are only about a dozen ambulances in usable condition in all of Aleppo province. Vehicles like ambulances are, of course, also vulnerable to gunfire.

The humanitarian emergency in Syria has made it necessary for people to take on jobs for which they are not trained. Many Syrian healthcare workers have fled the country, and those who remain do the best that they are able. Among those who remain are specialists, doctors-in-training and surgeons with no experience operating on war-related injuries. Dentists are performing minor surgeries, pharmacists are treating patients and young people are volunteering to work as nurses. This is a war, and everyones got to do it all, says one of them.

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No BlooD BANK
large quantities of blood are needed in order to treat patients with conflict-related injuries. the only blood bank in the Aleppo area was demolished in an air raid when the fighting began, so hospitals in the area have been struggling to deal with this difficult situation for months. Finding donors is not the problem many people are happy to give blood. the issue is, keeping the bags of blood cool. Most hospitals are not equipped with refrigerators. if a facility is fortunate enough to have one, a generator is required to keep the fridge running as there is presently no power in the region. in addition, hospitals in the area do not have the testing materials required to analyse and determine blood type. As a result, people who need urgent blood transfusions are given blood without the necessary tests having been carried out and the consequences can be fatal.

i heard about a pregnant woman who had gone to hospital to give birth, says Dr Natalie roberts. She needed a blood transfusion which was given but the blood used was not the right type. She died, and is not clear whether it was the haemorrhage, or the transfusion itself, that killed her.
MSF has provided a fridge, money for fuel, testing supplies and training to set up a new blood bank. this new facility now supplies hospitals in the Aleppo region. it is still at risk of becoming a military target.

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2. civilianS caught up in the cycle of violence

In the regions in northern Syria where MSF is working, people have suffered great loss 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, such as markets and bread queues which have been targeted by the air force. In addition to the physical devastation, the countrys social and economic systems have broken down, and civilians are the first to suffer. Despite a massive outpouring of local solidarity, the ongoing conflict has brought the healthcare system to its knees, while living conditions have severely deteriorated. Meanwhile, resources are running out and peoples capacity to help each other is being tested.

Since starting work in northern Syria, MSF has been witnessing how the violence is directly affecting civilians. Patients injured by shrapnel or bombs at the market or even in the breadline make it to hospital only thanks to the efforts of their fellow citizens willing to help each other despite the distances to health centres and the constant threat of bombings. Some villages are hit by rocket fire or have explosives dropped on them by helicopters on a daily basis, says Katrin Kisswani, an MSF coordinator in Syria. This has had a devastating effect on people. A few days ago, a helicopter dropped a couple of barrels with TNT and bits of metal inside right in the middle of a village. We treated the victims in our field hospital some of them were women and children. During

Civilians terrorised

exploratory missions, MSF teams have also come into contact with people who had been living without any outside assistance at all. Civilians have been traumatised by the conflict and live in constant fear of gunfire, rockets and missiles. They are even suspicious of one another: sometimes they would not give their real names out of fear their stories would become public and their families would be threatened. On 13 January of this year, 20 people were killed and 99 injured after a marketplace was bombed in Azaz. MSF treated 20 of the wounded, all of them civilians including five children. Only two days later, a further 44 patients received emergency treatment in another MSF facility, after several barrels of explosives were dropped on a village and a rocket landed in Idlib province.

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FeAr oF plANeS
Faotum H. 55 years-old, sits outside an MSF hospital after visiting her grandson. She recalls the buzzing of Syrian warplanes over Azaz, a town in northern Syria close to the turkish border, in the summer of 2012. An airstrike hit her home, though no one in her family was injured as they were not home, but the second floor was completely destroyed. the large hole and debris from the impact remained as physical reminders of the attack. A few months later Faotums grandson, six year-old Mohammed, was playing at home with his brothers when warplanes flew over Azaz.

the kids panicked and started to run downstairs. Mohammed did not see the hole and fell down it, broke his leg and injured his head, says the grandmother. it wasnt an airstrike, but the sound of the planes was enough to frighten the children and send them running. the boy was treated at an MSF field hospital in the region. His grandmother is relieved but remembers how hard it was to find medical assistance. We were told in Azaz that we had to go to turkey. in the end we came here, and he was admitted.

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

one afternoon at the end of December, i was waiting at the bakery to buy bread. there were about 300 people in the queue its the only bakery in town thats still open. id been waiting for three hours when suddenly a plane flew overhead and two missiles hit us. there was screaming all around me many people had been wounded. i felt disoriented; i felt as though my lips and tongue were burning. injured people were loaded into vehicles. i was taken to a health centre first in a wheelbarrow, then by motorcycle taxi. i was unconscious for three days. the second day, my brother brought me to another medical centre before finally bringing me here to the MSF hospital in a van. thats when they operated on me. im still having problems with my ears theres constantly a ringing in them and i cant really hear. the incredible thing is that my two daughters came away from it okay. A semi-collapsed wall protected them from the explosion, so they only had a few cuts and scrapes.
At the MSF hospital, a surgeon cleaned this mans wounds and the parts of it that had become necrotic, and sutured the small cuts on his face. the size of the wound on his left shoulder and the severity of the injury to his right hand meant that he had to be transferred to a hospital in turkey for reconstructive surgery, as the MSF facility isnt equipped to carry out such complex procedures.

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A health system in collapse
Before this conflict, Syria had a well-functioning health system. The country has trained health workers, medical expertise and a pharmaceutical industry. But today resources are depleted. Health networks are breaking down because of supply problems and drug shortages resulting from the collapse of the pharmaceutical industry or indirectly from international sanctions imposed on Syria. The intense violence makes accessing healthcare very difficult. In Homs, Aleppo and in the area around Damascus, snipers present a constant danger. Moving from one area to the other is often impossible, and entire communities are consequently deprived of medical care. In a medical emergency, patients face a grim dilemma: either forgo medical attention or risk finding themselves in crossfire.. Patients are often sent to under resourced health facilities, if theyre lucky enough to receive any care at all. In many hospitals care is first given to combatants, but large numbers of patients also need medical attention, be it for chronic illnesses (e.g. diabetes, cardio-vascular diseases, and kidney failure), obstetric care and post-operatory care, and have difficulty 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 difficult for people to access healthcare, 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 of thousands of cases of cutaneous leishmaniasis in northern Aleppo province. Local doctors in Deir ez-Zor reported to MSF that 1,200 cases of typhoid fever, which can be fatal, and 450 cases of cutaneous leishmaniasis had been registered by the end of February. Drugs for tuberculosis have been unavailable in the region for months. Diabetic patients require regular treatment and follow-up but at present they have been left to their 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 emergency doctor.

Giving birth in a war-torn country

Prior to the conflict, 95% of Syrian women gave birth with a skilled birth attendant. With the gradual collapse of the health system, this is no longer an option for most of them. If a pregnant woman is lucky, she might give birth with the help of a midwife or a traditional birth attendant. However women with complicated deliveries requiring surgical care have great difficulty in finding an appropriate facility. On 1 February of this year, a woman gave birth to twins by Caesarean section at an MSF clinic in northern Syria. The father of the twins said they searched for two weeks to find a hospital capable of performing the surgery. In the MSF hospital in Aleppo province, deliveries climbed from 56 in November 2012 to 183 in January 2013. MSFs medical teams have seen an abnormally high number of miscarriages and premature births among their patients, more than 30 in December and January alone. This is due to the stress generated by the conflict.

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Most of the families have fled 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.

Deteriorating living conditions

Displaced and isolated people

The cost of living has increased considerably, and bombing has cut off the supply of water and electricity in the north of the country. Since the beginning of December 2012, there has been no electricity in the eastern part of Aleppo, in Al Bab, and in the entire region up to Kilis. The price of fuel has risen significantly and now that it is winter, conditions are constantly cold and moist. People are using wood or fuel stoves to keep warm, which are often the cause of serious accidents. MSFs Elisabeth Jaussaud, who has returned from east Aleppo, says, In Aleppo, everything that 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 cars or armoured vehicles cant pass. Rubbish too is piling up all over the city. Another issue is the supply of food. Food prices have increased sharply in the northern provinces of Syria where MSF is present (Latakia, Idlib and Aleppo), so there have been major shortages of flour and baby formula. In response, MSF has donated baby formula and several tonnes of flour 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 identified.

According to the Office of the UN High Commissioner for Refugees (UNHCR), two and a half million Syrians have been displaced inside the country since the first protests broke out two years ago. Most of the displaced people are not living in camps many settle in buildings and public places, or are constantly on the move. Living conditions are very poor for the internally displaced, while host communities are also under strain. Access to large parts of the country is still very difficult. As you go south from the Turkish border, the level of assistance decreases. It is also difficult for assistance to reach densely populated areas and the desert regions in the east. The food shortages are so acute that current supply and solidarity networks cannot cope. In areas under government control, such as the western parts of Aleppo city, people are living in enclaves surrounded by the armed opposition. It is impossible to supply humanitarian assistance from Damascus into these areas. Faced with a situation that is relentlessly worsening, an increasing number of Syrians are fleeing the country. According to the UNHCR, one million Syrians have been either registered or are waiting to be registered as refugees mainly in 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 been sufficient to effectively respond to their basic needs. Meanwhile, their living conditions have continued to worsen through the harsh winter conditions and sub-zero temperatures.

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3. obStacleS to increaSing aid for Syria

There are major obstacles preventing the increase of aid to both government and rebel-held areas. The government is limiting humanitarian aid; because of the control exercised by Damascus, assistance can hardly be expanded and aid organisations face huge difficulties crossing front lines. Meanwhile, in the north of the country, insecurity caused by fighting and bombing is compounded by political and diplomatic constraints , seriously limiting the amount of aid.

Since 2012, international aid for Syrians inside the country has been mainly deployed from Damascus by 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 the Syrian Arab Red Crescent and local organisations, which are authorised by the Syrian government to distribute the aid on the ground. Operations are also under the responsibility of the Syrian ViceMinister of International Affairs and Expatriates. Though there is currently insufficient humanitarian aid to meet the massive needs, it will be difficult to get more and more effective aid into the country. For one thing, the government is not permitting any more international NGOs to work in government-held territory indeed, MSF has been refused access to these areas, despite several requests. Also, humanitarian aid organisations are required to distribute aid through local organisations, who are already operating at full capacity and whose scope of operations is limited geographically. These constraints also significantly limit the capacity of aid agencies tolerated by Damascus to reach people in the opposition-held north of Syria. According to Valerie Amos, UN under-secretary-general for humanitarian affairs, other options for aid distribution, like humanitarian operations led from neighbouring countries, are not currently feasible without government authorisation or a separate UN Security Council resolution.

Control of assistance in government areas

About a dozen international NGOs are present at the Syrian borders attempting to get aid into the countrys interior. This aid was first limited to sending medical supplies for groups of Syrian doctors working clandestinely to treat injured people in makeshift hospitals. Some aid has been provided in the displaced peoples camps along the Turkish border. MSF first started supporting these doctors this way. With the consolidation of territory controlled by the opposition, MSF was able to enter and open three hospitals in the north of the country. This was done unofficially, 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-

Aid to rebel-held areas - limited and piecemeal

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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 in the 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 revolutionary coordination councils). Narrow areas along the borders are de facto exempt from the bombing. But the supply of aid dwindles further inland from the border, such as in the Deir ez-Zor region, which is particularly neglected. Another obstacle for the provision of aid is of a political nature. In the north of Syria, international aid providers are struggling to find ways to collaborate efficiently with local authorities and Syrian aid networks. One issue is that there are many representatives and leaders. Humanitarian actors struggle to gauge the real importance and operational performance of the different representatives they come across. Futhermore, humanitarian actors distrust them all the more as these persons can be affiliated with different and competing networks (political, military, or religious, for example). The final obstacle is administrative. Though neighbouring countries tolerate NGOs engaged in cross-border humanitarian operations into Syria, they are not willing to grant them the logistical and administrative support that comes with official permission. Aside from slowing down the delivery of aid, this semi-underground status also conflicts with the financing rules for some donors who are reluctant 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 provide them with direct financial and (officially non-lethal) military aid. This being the case, its hard to see what is stopping Syrias neighbouring countries and these financial donors from officially recognising and providing financial support to humanitarian cross-border operations.

Although the current set-up is intended to cover all the existing needs in Syria, the national and international aid provided beyond areas controlled by Damascus is limited. This is due to the huge difficulty involved in imposing a temporary ceasefire, which would be necessary to get material and teams 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: Mounting cross-line operations is challenging, not least because as in every conflict neither side is keen to see us crossing into the area held by their enemy. Armed rebel groups, meanwhile, show great mistrust towards the Syrian Red Crescent, which is perceived as pro-governmental despite the dedication of its members (since the beginning of the conflict, seven Red Crescent volunteers and eight UN employees have been killed on-mission). To cover the needs of civilians, the capacity of humanitarian actors to provide impartial aid on the whole Syrian territory must be increased and cross-border operations must be facilitated, as a matter of urgency.

Danger of humanitarian operations across frontlines

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At the end of January 2013, more than 60 countries committed to providing more than 1.5 billion dollars in humanitarian aid for the Syrian population. This amount, meant to cover urgent humanitarian needs for the first half of this year, can be contrasted with the small sum that the UN Office for the Coordination of Humanitarian Affairs (UNOCHA) was actually able to obtain to cover its action plan in 2012. The plan for 2013 includes a regional response for refugees, estimated at $1 billion US for 1.1 million people, and another estimated at $520 million US for 4 million people directly or indirectly affected by the current events inside Syria. Yet, as of 19 February, the UN action plan had only received 20% of the necessary financing. This aside, the difference between the amount of financing for aid going to refugees and the amount allocated to Syrians inside the country illustrates that the current system is unable to respond to the current emergency inside Syria.

Insufficient aid

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4. aSSiStance failing Syrian refugeeS

According to official estimates, 1 million Syrian refugees are registered or awaiting registration 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 fleeing Syria each day. Most of them are reported to be women and children.
The situation of the refugees fleeing Syria emphasises the failure of the international aid system to respond to the Syrian crisis. Although access and security in the neighbouring countries are not a major problem, the international aid system has failed at anticipating and responding to the growing needs of the refugees. The massive influx of refugees pouring into Syrias neighbouring countries is weakening further already fragile refugee reception set-ups and worsening the already dire situation of scattered refugees in Lebanon. In Jordan and in Iraq the living conditions in the refugee camps are grim. The camps are saturated and hygiene is poor, due to shortages of latrines and showers. People are living in crowded and unheated tents that offer little protection against the bitter winter. Earlier this year rainstorms and snow have plunged some camps into no refuge. In Lebanon where there are no official camps for Syrian refugees, an increasing number of people live in inadequate collective shelters, farms, garages, unfinished buildings and old schools. According to a survey conducted by MSF in December, 50% of the Syrian refugees in Lebanon are not receiving the required medical treatment because they cannot afford it. Food also is a growing issue. MSF teams have seen cases of women having to feed their babies with tea because they could not afford to buy milk.

Psychological distress is widespread among the refugees whether they are men, women or children. Most of the refugees interviewed by MSF in Lebanon and Iraq reported they fled Syria because of the insecurity but also because of the deterioration of their living conditions in Syria (shortages of food, water and fuel and lack of access to medical care). Thousands of Syrian refugees face an unacceptable situation. After fleeing a war zone and leaving everything behind them, people still have to wait weeks or even months before they are officially registered as refugees and receive a much needed assistance. Many families are living in dire conditions with very little assistance, while others simply not getting any aid at all: roughly one in four of the registered refugees interviewed in Lebanon said they had not received any assistance, while 65% said they had received only partial assistance that did not cover the families needs. For Iraq, Jordan, Lebanon and Turkey, which host nearly all the Syrian refugees, the cost today is growing and the host populations who have been very welcoming over the past two years 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 in place are today dysfunctional and will most likely

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remain so if the influx of refugees continues. A late recognition of the magnitude and duration of the crisis and the ever growing numbers of refugees are the main reasons that explain the delays in the deployment of a response commensurate with the needs. But the level of assistance to the Syrian refugees must be urgently increased today in order to avoid a full blown humanitarian crisis. There must be a more expansive, concerted, and effective humanitarian response to provide these people with a relief from the conflict plaguing Syria, and ensure that their humanitarian and medical needs are met. Since 2011 MSF has expanded its work with Syrian refugees in Lebanon, Jordan, Iraq and Turkey. 25 official reception points for refugees along the border, and many more unofficial crossing points. Some 40,000 Syrian refugees crossed the border in January alone. Zaatari camp, near the Syrian border, is now home to more than 60,000 refugees. The living conditions are totally inadequate. Hygiene conditions are poor due to a severe shortage of latrines and showers. This winter has been particularly harsh and Zaatari camp was partially floodedin January. Authorities have begun to relocate residents to prefabricated bungalows but most are still living in unheated tents that offer little protection from the elements.

in iraq
The Kurdish Region Government (KRG) is hosting the Kurdish population that has fled Syria, whilst the central government in Baghdad has opened two camps in the south-western part of Iraq (Al-Qaim and Al Waleed camps). According to the UNHCR, as of mid February 2013, there were 96,270 refugees in Iraq including over 75,500 in the Kurdish Region. - Domeez camp was established in Duhok province in April 2012 and is managed by the UNHCR and the KRG authorities. Initially designed to host 1000 families, the camp is now home to more than 50,000 people. Water and sanitation services are poor. The difficult living conditions for refugees are compounded by the winter weather and sub-zero temperatures. - Al Qaim border crossing, the only official border crossing for a distance of 400km, remains closed. Although some of the sick or wounded are allowed to cross the border to seeking medical assistance, MSF is concerned about the fate of people fleeing the ongoing fighting in Deir Al Zoyr in Syria, who are unable to reach safety in Iraq.

in lebanon
Out of 300,000 Syrian refugees officially registered today in Lebanon according to the UNHCR , 220,000 have crossed the border since October. Large numbers of families are living in unfinished buildings, garages, warehouses and encampments which are utterly unsuitable to face the hardship of the winter. The main identified needs - in studies conducted by MSF in December 2012 - are primarily accommodation, food, winterisation items, primary and secondary health care, and mental health care. The Lebanese community has made a huge effort to assist the refugees. Though the situation in Lebanon remains relatively stable, the economic, social and political spillover of the war in Syria is having an impact over Lebanon, exacerbating sectarian tensions in impoverished neighborhoods of Tripoli. The Lebanese government has stated that it has no longer the means to face the burden of the refugees alone, and has asked the international community for support.

in Jordan
Over 240,000 Syrians refugees are registered or awaiting registration in Jordan. There are now

in turkey
In Turkey, the refugee camps are managed by the Turkish authorities with the support of local actors such as the Turkish Red Crescent.

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According to the Turkish authorities, 183,540 Syrians have sought refuge in seven provinces and are hosted in 14 camps that are all nearly at capacity. Estimated figures of unregistered people range from 70,000 to 100,000 people. In Kilis the estimated figures of both registered and unregistered Syrians inside and outside the camp are around 40,000. New camps are being opened but they cannot cope with the massive influx of refugees. Many people remain stuck at the Syrian border in so called transit camps, waiting to be transferred to the camps. In addition, many of them try to cross by their own, settling in Kilis and surrounding areas, sometimes as a first step in their exodus.

trAppeD By WAr, tHey eScApeD AND tHey SUrvive testimonies of Syrian refugees lebanon
leBANoN
After a while they started bombing the towns and villages the armysent tanks to demolish my house. they broke down the walls and entered with the tanks through the columns. Nothing was left of our house. We fled to another village, but there we were caught by heavy shelling, so i took the children who were terrified of the bombs and brought them to Aarsal in lebanon , aid a fatherof eight to our teams. 400 bombs were falling per hour . We could not cope with the situation anymore, we have children. We had to sleep under trees, in a cave (grotto), in a valley to hide from the bombs. Finally we had no other choice than to flee to lebanon to protect our children and our lives.

irAq
i arrived from Syria four days ago. our economic situation there was really bad. We came from qamishli, where there is no gas, no electricity, no water, there is nothing. the city is completely besieged. We didnt have any fuel for the heaters so we had to use tissues and whatever materials we could find. the children got ill because of the smoke, they suffered from respiratory irritation. this is why we came here. the trip was really difficult and very long, said a woman who arrived with her husband and five young children. the family is still waiting for a shelter.

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5. MSf in and around Syria

Prior to the Syria uprising, MSF was working in Damascus providing health care for migrants. However, this project was closed in April 2011. Then MSF repeatedly requested official access from the Syrian government in Damascus to be able to provide 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 the government.
Initially MSF started supporting groups of Syrian doctors who were treating the wounded by supplying them with medicines and medical material. MSF re-entered the rebel held areas of the country unofficially in mid 2012 but were unable to enter government held areas. MSF now has three field hospitals in in northern Syria and which the Syrian authorities have been informed of. Whilst initially MSF focused on providing emergency and surgical care, activities have extended to include primary health care consultations, maternal care, organising vaccination campaigns against polio and measles. MSF alsoprovide donations of treatments for cutaneous leishmaniasis;communicable diseases, such as typhoid and chronic illnesses such as asthma, diabetes and cardio-vascular diseases. In Syria, over 1500 surgical procedures and over 20,800 out-patient and emergency consultations have been carried out by MSF teams between June 2012 until the end of February 2013. Many patients 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 shifting frontlines and whether it is possible to refer patients. Several other health facilities have been set up by Syrian doctors and other medical organizations to 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 significant number of MSFs patients need treatment for chronic disease, accidental trauma, or assistance during childbirth. MSF is also providing training in mass casualty management, triage, and emergency care to Syrian health personnel who need support in the management of war-wounded patients. Specific assistance is also being provided to medical facilities, such as setting up a blood bank in a health structure in Aleppo area. Our teams regularly carry out adhoc distribution of relief items including baby milk and flour for affected 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 field hospitals and clinics in Syria, including into government controlled areas.

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MSF started supporting local initiatives to help refugees in Turkey in August 2011, and has since then increased its activities to include assistance to refugees in Lebanon, Iraq and Jordan. From the start of 2012 until January 2013, MSF has provided nearly 69,000 medical and mental health consultations to refugees in these four countries, mainly in Lebanon and Iraq. In Lebanon, MSF is assisting Syrians through primary health care services, treatment of chronic diseases, antenatal care services, and mental health care, as well as distributing relief items. MSF is currently 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 fleeing 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 immunization and carrying out targeted distributions of hygiene kits as well as improving safe water supplies and efficient sanitation. MSF is also working in Al Qaim supporting the border clinic run by the Iraqi Ministry of Health and in recently started providing mental health services in two refugee camps in the area. In Jordan MSF provides reconstructive surgery to war wounded refugees. Currently, Syrian surgical cases (mainly orthopaedic) represent 40% of the new admissions in MSF hospital in Amman, where they are offered physiotherapy, psychosocial support and post-operative care. MSF also runs outpatient consultations for Syrians from the Amman hospital. In Turkey MSF is providing mental health support in partnership with Helsinki Citizens Assembly organization to the Syrian refugees living inside and outside camps, and has distributed relief items for refugee families living outside the camps and who are not helped by the existing aid system.

Extending assistance for refugees in neighbouring countries

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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 million
All our funding for programmes in and around Syria comes from private donations.
HUMAN reSoUrceS (locAl AND iNterNAtioNAl teAMS)
Syria: turkey: lebanon: iraq: Jordan: totAl : 229 58 (includes support and coordination for Syria) 118 75 (for refugee camps, not including teams working in other projects in iraq) 64 (for refugee camp, not including the Amman Hospital project) 544 teams members working in and around Syria

MeDicAl ActivitieS WitHiN SyriA (Aleppo AND iDliB goverNorAteS) UNtil FeBrUAry 2013
1560 surgical acts were carried out by MSF in three hospitals in Syria, mostly for violence related injuries. over 20,800 medical consultations were carried out, including primary healthcare consultations and emergency consultations. 368 babies were delivered, mostly in the maternity ward in Aleppo, from November 2012 to January 2013.

DiStriBUtioNS iN SyriA
over 166 tons of material were delivered including kits for treating wounded, for treating burns, surgical kits and donations of medical equipment such as oxygen extractors, transfusion kits, etc. in addition to this, 4,000 treatments for typhoid and 500 treatments for cutaneous leishmaniasis were provided in February 2013 in Deir ezzor governorate. relief items including wheat flour have been distributed in Deir ezzor and idlib governorates, and to 7500 people living in transit camps next to the turkish border in Aleppo governorate.

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MeDicAl ActivitieS AroUND SyriA
consultations for refugees (outpatient, mental health, postop follow up) lebanon: outpatient and mental health iraq medical consultations turkey individual mental health consultations Jordan outpatient consultations Jordan post operative follow up totAl opD / MeNtAl HeAltH 25250 40000 623 2653 201 68727

in addition to this, in Jordan 190 patients underwent surgery in MSFs reconstructive surgery programme in Amman and 125 patients were provided with physiotherapy to help recover from their injuries.

DiStriBUtioNS AroUND SyriA

Nearly 55,000 relief items have been distributed in lebanon to refugees who fled Syria. Since mid January our teams have also distributed fuel 3000 fuel vouchers to 500 families in the Bekaa valley. targeted distributions of relief items (blankets, hygiene kits) have also been carried out in iraq. in turkey, Non Food items (blankets, hygiene kits, stoves, charcoal) were distributed to nearly 6900 Syrian refugees who were not living in the camps and who had not previously received

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