With the war in its fifth year, the situation for the brutalised Syrian civilian population trapped between warring factions is becoming ever more desperate. More and more help is needed, according to the United Nations and international relief organisations, but what aid is being offered on the ground is insufficient, paltry even.
In January, the United Kingdom-based Syrian Observatory for Human Rights reported that 76,000 people had been killed in the conflict last year, marking its bloodiest year yet. Of these, 17,791 were civilians, including 3,501 children.
Dounia Dekhili, a programme manager for Médecins Sans Frontières (MSF), chooses not to mince her words. “For me, it’s the first crisis that I’ve seen that has such a large-scale violation of humanitarian rights.”
Dekhili’s latest posting is in Dubai, but for the past decade, she has been part of MSF emergency teams in Nigeria, Ivory Coast, Haiti and Mali.
Since the civil war began in 2011, the international organisation has worked to provide trauma care as well as basic health coverage to the hundreds of thousands of ordinary Syrians whose lives have been torn apart. But as time has gone on, the amount of help they have been able to offer has been shrinking. From an estimated 2,500 doctors working in Aleppo at the start of the conflict, for example, fewer than 100 remain. The rest have been killed, kidnapped or forced to flee. Those still on the ground operate in the most rudimentary of settings with extremely limited supplies and space.
“We know doctors that we were working with, and places that we’re supporting that have been bombed. Doctors that have been killed, not only by the government but even from the other sides,” Dekhili says.
“The difficulty to deploy as we could is a huge frustration, but the biggest frustration is to see our Syrian colleagues systematically targeted, and to see hospitals targeted as any other military target from all the parties.”
Before the fighting started, Syria had a relatively developed and efficient healthcare system with well-functioning public and private hospitals.
“As soon as the contestation started in March 2011, we had reports that the protesters were shut out by the security services and even hunted in the hospitals; some disappeared. Medical staff were prevented from providing care,” Dekhili says. “We also knew that the blood bank, for example, was under the control of the security [forces] because blood is mainly meant for trauma cases and the trauma cases were mainly the wounded, and the wounded were protesters.”
Victims of the violence began to shun public hospitals and sought medical care in private homes and even farms, instead.
Private clinics that maintained some independence from the government began falsely documenting patients so, if questioned, they could deny treating trauma cases.
Pharmaceutical supplies were, and still are, confiscated, and essentials such as gauze dressings have become part of an illicit trade, with those caught selling them at risk of arrest or worse.
Late in 2011, MSF was contacted to try and intervene in the worst-affected areas in the fighting, as the charity had been doing so successfully in conflict zones for more than 40 years.
“MSF started to have contact with those doctors and nurses that were obliged to work clandestinely,” Dekhili says. “We were contacted because we had a project in Jordan that opened in 2006 to treat Iraqi war victims. We tried from the beginning to ask for authorisation for exploratory missions with the Damascus authorities [but] this was never accepted. So we were solicited to help those doctors with supplies across the border.
“Treating a patient was as bad as having a Kalashnikov. Treating the wounded and being in touch with the foreign organisation was something more dangerous for them,” she says of the doctors’ courage.
By June the following year, the group had used its networks within Syria to negotiate with opposition armed groups to establish a basic but essential understanding: that a hospital is a sanctuary, free of any political or military intervention.
This is one the conditions required before MSF can operate in a conflict zone; the other two are independence to assess needs and an undertaking that aid and assistance is not diverted. Eventually, MSF was able to open seven medical outposts of its own and provide support for other medical facilities operating underground in besieged areas. As the country’s health system failed, the charity also began to support more general needs such as maternity care and a measles vaccination campaign.
Then the ground rules changed. On January 2 last year ISIL kidnapped 13 MSF staff – including eight Syrians – from a medical centre in northern Syria. The Syrian nationals were released within hours but the five remaining international staff were held captive for five months in “very difficult conditions”, according to Dr Mego Terzian, president of MSF France. “We had to withdraw our team and close our project in the ISIL area,” Dekhili says. “We had to close three hospitals.” Today only three MSF-run hospitals remain open in Syria, one in Atmeh and two in Aleppo.
“We know that the needs are huge in Syria. It’s not only medical needs. There is no food going in, no electricity, and this has an impact on the health of the population. The worst thing is there is a generalised and, sadly, kind of accepted fact that the medical mission is a target.”
In March, Dr Joanne Liu, the international president of MSF, referred to the Syrian people’s cries for help as having become a “background murmur” of the civil war. “Doctors Without Borders should be running some of the largest medical programmes in its 44-year history. Why isn’t it?”
Dekhili, who is from Algeria, references its work in the Central African Republic, which in 2013 descended into violence and forced thousands of people to flee, as an example of the good work that can be done when all parties can agree on MSF’s three conditions.
“It’s not the same size of country or population, but it also has huge violence, a civil war. Here MSF had 10 facilities, we deployed 300 international staff and we had over 2,000 national staff.” It also supported more than 100 medical facilities.
In Syria, MSF is resigned to dramatically limiting its work and watching as thousands of people go without basic medical care.
The effects of this are expected to be seen for decades to come, even when the current conflict becomes part of the country’s bloody history.
“You have a lot of parties involved in the political and diplomatic game. What we are expecting is that they take responsibility to separate the human issue from the rest and to defend it.
“Human beings have to be protected. The civilian population cannot be punished for everything.”
Lost voices: doctors speak out
“There was a pregnant woman who was trapped during the time we were under full siege. She was due to deliver soon. All negotiation attempts to get her out failed. She needed a caesarean operation, but there was no maternity hospital we could get her to, and I had never done this operation before.
“A few days before the expected delivery date, I was trying to get a working internet connection to read up information on doing a C-section. The clock was ticking and my fear and stress started to peak. I wished I could stop time, but the woman’s labour started. The atmosphere was tense already, with mad shelling hammering the area. The bombardments had reached a deafening level. We brought the woman into the operating theatre and I did the operation. Joy overwhelmed me when we knew the baby girl was healthy, and her mother, too.
“In this madness, our work as surgeons is to save as many lives as we can. Sometimes we succeed, and sometimes we fail. It is as if we repair the damage that the war left. But this operation was not the usual damage repair; it helped bring new life to this Earth. It was a magical moment; a temporary truce that death could not penetrate.”
Dr S is a young surgeon who graduated shortly after the outbreak of the crisis in Syria. He now works in a makeshift hospital in a semi-rural neighbourhood to the east of Damascus, supported and supplied by MSF on a monthly basis.
“It’s been three years since this area has been reachable by cars on regular roads. Whether it is for food, medicine or fuel, we can only go through a muddy and difficult path accessible only by foot, donkey or with small boats across Lake Houleh. We only have one path for supplies, but we call it the death path because there are snipers; whatever reaches us is covered in the blood of the people who have risked their lives to get it here.
“With MSF support, we can at least count on some medicine; it covers more than half of our needs, but we still face stock ruptures. It is impossible for us to store medicine and we are permanently in daily consumption mode. When we can only get hold of one box at a time, how much medicine can we stock for 90,000 people?
“People are drinking contaminated water and coming to the hospital with infections. Once upon a time, Al Houleh was known for its crops and agricultural produce. Now it is too dangerous to go out into the fields and harvest the land. The basic food supplies that are available in the market are too expensive for the majority. People come to the hospital sick from bad water and poor nutrition.
“We have days with two hours of electricity, and weeks without any at all. Our hospital is run by generators. It has the only two neonatal beds that are available in the entire area, and sometimes we are forced to put two babies in one bed. Medically, this is unacceptable, but we don’t have any other options.
“The hospital I’m working in has been bombed three times. The last time was seven months ago. The war planes were flying low, and the air strikes meant for the hospital hit a building next door and two people died. That is why our medical departments are spread out across different buildings, in order to avoid losing everything in a few minutes.
“We see patients all morning and all night. The days are very long, and the idea of having time for anything other than work is a distant dream, but when I can, I spend time with friends and family. I try to remember that we had good times once, and that it will happen again. It gives me the strength to continue.”
Dr A is the director of a key field hospital in Al Houleh in north Homs, an area with about 90,000 people living under siege.
“Many tireless volunteers support the running of the field hospitals. They don’t have degrees, but they have war experience. I would give them all diplomas if I could. It’s impossible for us to get medicine in any official way. Even basic supplies are scarce, so we started making our own gauze by hand. We make very little, but it’s better than nothing. Blood bags and anaesthetics are virtually impossible to procure; people risk their lives to carry small amounts. Vaccinations used to be allowed in, but for the last four months even this wasn’t possible.
“Flour and yeast are forbidden; the checkpoints allow eight loaves of bread at a time. We use whatever grains are available – it no longer tastes like bread, but we eat it. Whatever is available on the market is so expensive, up to four or five times what it used to cost before the war. Even those who had a little money before don’t have much left now. Electricity and clean water are considered luxuries.
“All of us here are living under great pressure. I haven’t left this area in more than three years – you can’t imagine how that feels. I have three children, but I don’t see them enough. I am like a robot working day and night, and when I can, I go home to my family.
“The violence has forced so many people to lead entire lives underground; schools, hospitals, homes are all below ground level. Our home is on the second floor and only last Thursday the building was hit by shelling. Fear is dictating our lives, but while I am alive I choose to live above ground.”
Dr E is a surgeon in one of the field hospitals in north Homs, where about 350,000 people have been living under siege for more than a year. Northern Homs MSF supports eight field hospitals and three medical points and provides approximately 50 per cent of its medical and other needs.
Mitya Underwood is a senior features writer at The National.
