Syrian mother and child near Ma'arat Al-Numan, rebel-held Syria, in autumn 2013. Credit: Shelly Kittleson/IPS

By Shelly Kittleson
BEIRUT, Jul 19 2014 (IPS)

Gaunt, haggard Syrian children begging and selling gum have become a fixture in streets of the Lebanese capital; having fled the ongoing conflict, they continue to be stalked by its effects.

Most who make it across the Syria-Lebanon border live in informal settlements in extremely poor hygienic conditions, which for many means diarrhoeal diseases, malnutrition, and – for the most vulnerable – sometimes death.

By the end of January, almost 40,000 Syrian children had been born as refugees, while the total number of minors who had fled abroad quadrupled to over 1.2 million between March 2013 and March 2014.Most who make it across the Syria-Lebanon border live in informal settlements in extremely poor hygienic conditions, which for many means diarrhoeal diseases, malnutrition, and – for the most vulnerable – sometimes death.

Lack of proper healthcare, food and clean water has resulted in countless loss of life during the Syrian conflict, now well into its fourth year. These deaths are left out of the daily tallies of ‘war casualties’, even as stunted bodies and emaciated faces peer out of photos from areas under siege.

The case of the Yarmouk Palestinian camp on the outskirts of Damascus momentarily grabbed the international community’s attention earlier this year, when Amnesty International released a report detailing the deaths of nearly 200 people under a government siege. Many other areas have experienced and continue to suffer the same fate, out of the public spotlight.

A Palestinian-Syrian originally from Yarmouk who has escaped abroad told IPS that some of her family are still in Hajar Al-Aswad, an area near Damascus with a population of roughly 600,000 prior to the conflict. She said that those trapped in the area were suffering ‘’as badly if not worse than in Yarmouk’’ and had been subjected to equally brutal starvation tactics. The area has, however, failed to garner similar attention.

The city of Homs, one of the first to rise up against President Bashar Al-Assad’s regime, was also kept under regime siege for three years until May of this year, when Syrian troops and foreign Hezbollah fighters took control.

With the Syria conflict well into its fourth year, the U.N. Security Council decided for the first time on July 14 to authorize cross-border aid without the Assad government’s approval via four border crossings in neighbouring states. The resolution established a monitoring mechanism for a 180-day period for loading aid convoys in Turkey, Iraq and Jordan.

The first supplies will include water sanitation tablets and hygiene kits, essential to preventing the water-borne diseases responsible for diarrhoea – which, in turn, produces severe states of malnutrition.

Miram Azar, from UNICEF’s Beirut office, told IPS that  ‘’prior to the Syria crisis, malnutrition was not common in Lebanon or Syria, so UNICEF and other actors have had to educate public health providers on the detection, monitoring and treatment’’ even before beginning to deal with the issue itself.

However, it was already on the rise: ‘’malnutrition was a challenge to Syria even before the conflict’’, said a UNICEF report released this year. ‘’The number of stunted children – those too short for their age and whose brain may not properly develop – rose from 23 to 29 per cent between 2009 and 2011.’’

Malnutrition experienced in the first 1,000 days of a child’s life (from pregnancy to two years old) results in lifelong consequences, including greater susceptibility to illness, obesity, reduced cognitive abilities and lower development potential of the nation they live in.

Azar noted that ‘’malnutrition is a concern due to the deteriorating food security faced by refugees before they left Syria’’ as well as ‘’the increase in food prices during winter.’’

The Syrian economy has been crippled by the conflict and crop production has fallen drastically. Violence has destroyed farms, razed fields and displaced farmers.

The price of basic foodstuffs has become prohibitive in many areas. On a visit to rebel-held areas in the northern Idlib province autumn of 2013, residents told IPS that the cost of staples such as rice and bread had risen by more than ten times their cost prior to the conflict, and in other areas inflation was worse.

Jihad Yazigi , an expert on the Syrian economy, argued in a European Council on Foreign Affairs (ECFR) policy brief published earlier this year that the war economy, which ‘’both feeds directly off the violence and incentivises continued fighting’’, was becoming ever more entrenched.

Meanwhile, political prisoners who have been released as a result of amnesties tell stories of severe water and food deprivation within jails. Many were detained on the basis of peaceful activities, including exercising their right to freedom of expression and providing humanitarian aid, on the basis of a counterterrorism law adopted by the government in July 2012.

There are no accurate figures available for Syria’s prison population. However, the monitoring group, Violations Documentation Centre, reports that 40,853 people detained since the start of the uprising in March 2011 remain in jail.

Maher Esber, a former political prisoner who was in one of Syria’s most notorious jails between 2006 and 2011 and is now an activist living in the Lebanese capital, told IPS that it was normal for taps to be turned on for only 10 minutes per day for drinking and hygiene purposes in the detention facilities.

Much of the country’s water supply has also been damaged or destroyed over the past years, with knock-on effects on infectious diseases and malnutrition. A major pumping station in Aleppo was damaged on May 10, leaving roughly half what was previously Syria’s most populated city without running water. Relentless regime barrel bombing has made it impossible to fix the mains, and experts have warned of a potential humanitarian catastrophe for those still inside the city.

The U.N. decision earlier this month was made subsequent to refusal by the Syrian regime to comply with a February resolution demanding rapid, safe, and unhindered access, and the Syrian regime had warned that it considered non-authorised aid deliveries into rebel-held areas as an attack.

Syrian refugee children learn to survive at a camp in north Lebanon. Credit: Zak Brophy/IPS.

By Katelyn Fossett
WASHINGTON, May 14 2013 (IPS)

Humanitarian assistance groups in Washington are warning that the health care system has become a deliberate target in the increasingly brutal civil war in Syria, presenting major challenges to addressing the humanitarian and refugee crises spurred by the conflict.

In a meeting with U.S. President Barack Obama on Monday, UK Prime Minister David Cameron stressed the centrality of the unfolding health crisis, emphasising the need in Syria to “care for trauma injuries, help torture victims to recover, [and get] Syrian families clean drinking water”.

Health aid is meeting significant obstacles, though, as the public health system in Syria reportedly has been largely dismantled after being targeted by Bashar al-Assad’s regime, which has wiped out a third of the hospitals in the country.

“The systematisation of the attacks [in Syria]…certainly served its purpose,” Stephen Cornish, executive director at Médecins Sans Frontières (MSF) in Canada, said recently at a panel discussion in Washington. “It created a flight of many medical personnel and destroyed large numbers of hospitals and interrupted public healthcare in a significant way.”

According to the Violations Documentation Centre, a Syrian human rights organisation based in Damascus, 469 health workers are currently imprisoned in Syria. Tom Bollyky, a senior fellow at the Council on Foreign Relations, a Washington think tank, estimates that around 15,000 doctors have been driven out of the country.

Bollyky noted that these attacks are one conflict’s manifestation of a disturbing global trend in which medical facilities and personnel become more frequent combat targets in conflict zones. In a March report, the Independent International Commission of Inquiry on the Syrian Arab Republic accused the Assad regime and opposition groups of strategically targeting medical facilities and personnel."Attacking medical personnel is a way of depriving a population of the humanitarian support they need."
-- Tom Bollyky

“Attacking medical personnel is a way of terrorising a population and depriving them of the humanitarian support they need,” Bollyky told IPS.

He pointed to similar instances in the Middle East and Asia, particularly coordinated attacks by the Taliban on polio immunisation volunteers in Afghanistan and Pakistan. On Monday, the Taliban announced it was halting its years-long effort to sabotage the campaign to eradicate polio among children in these two countries.

Such attacks are specifically outlawed in the Geneva Conventions, which entitle hospitals and medical staff to protection from hostile fire.

“Medical personnel are absolutely protected under international law,” Bollyky noted. “There is no circumstance where it is okay to attack medical personnel or facilities, and it is certainly happening on both sides.”

Silent casualties

The targeting of the Syrian health care system has not only left those wounded by combat without urgently needed care but has also exacerbated a public health crisis brought on by the poor living conditions of refugee camps outside of Syria.

Refugees from the conflict currently number more than one million, and the United Nations is warning that figure could swell to 1.5 million by the end of this year. That number is dwarfed by the more than 4.2 million Syrians who are displaced within Syria.

In addition to the systematic targeting, Syrian medical facilities are reportedly being “cannibalised” to serve military ends.

Zahir Sahloul, a doctor with the Syrian American Medical Society, told an audience on Friday about the looting of the two main hospitals in Aleppo – an eye hospital and a children’s hospital – that now serve as bases of operations for military battalions.

“Besides the destruction of the public health system, there is no sewer system,” Sahloul said “[There is a] lack of hygiene because of lack of electricity and sometimes water…and lack of diesel fuel. And because of that, you have a resurgence of some of the epidemics that weren’t there before.”

Chronic illnesses that were relatively easily treatable before the outbreak of the conflict – diabetes, or high blood pressure, for example – are now deadlier than ever, leading to what MSF’s Cornish called “silent casualties”.

These patients can’t be referred outside of the country because they aren’t considered emergency cases. But they also can’t be treated inside Syria because the necessary facilities and healthcare providers simply don’t exist anymore.

“Folks who have cancer and had their chemotherapy interrupted, all they can have is palliative medicine,” Cornish said. “And slowly, day by day, they die.”

Health workers are increasingly ill-equipped to deal with these growing problems, expert say, as their capacities are being undercut by suspicions over loyalty.

“In Syria, if you are a physician who is…’treating people from the other side’, you put your life at risk,” Sahloul said.

As humanitarian groups try to find solutions to the challenges to health and humanitarian assistance, observers appear united in their calls to the international community to ramp up pressure on both sides to stop hospital and medical staff attacks and to have more respect for international humanitarian standards.

Geneva Call, a non-governmental organisation in Geneva that focuses on engaging non-state actors in international humanitarian law, released several short video spots promoting respect for international humanitarian standards. One of the videos’ titles was “Respect and Protect Medical Personnel and Objects”.

Tom Bollyky suggested that treating these violations with more seriousness in the International Criminal Court– and recognising the international community’s responsibilities in combating them – would be a step in the right direction.

“You have seen a surge in these attacks, but you have not seen a surge in the indictments being brought against the people behind them,” he said. “The international legal system is not known for being expeditious, but it would be a form of real condemnation.”