MSF in Syria

Despite the extent of the crisis and people's needs, MSF is significantly constrained in its presence and medical activities in Syria, mainly due to insecurity but also due to a lack of agreements and authorisations. These constraints are as present today as they were a year and a half ago. To this date, the Syrian government has not granted us authorisation to work in the country.

MSF nevertheless continues to directly operate six health facilities in the north of Syria, and puts significant energy into providing the best possible support to more than 150 health facilities countrywide, in areas where MSF cannot be directly present.

MSF teams also work in the countries neighbouring Syria, providing assistance to refugees and host communities.

The humanitarian situation

After five and a half years of intense conflict, the situation in Syria keeps deteriorating, with ever-increasing unmet needs and suffering. It is estimated that 4.8 million people have fled the country, and another 6.5 million people are internally displaced (source: OCHA). This represents nearly 50 per cent of the total population. 

The ‘humanitarian system’ is failing in Syria. Assistance, including access to food and medical supplies, remains appallingly insufficient. The pervasive daily reality for many people in Syria is one of fear, deprivation, and a struggle to survive. Through many parts of the country access to medical care is dire due to a crumbling health system. Many hospitals are facing critical supply shortages, and there are ever-diminishing numbers of health workers, as medics have fled or been killed.  From the beginning of the conflict medical staff and medical facilities have been targeted.

Aleppo is in an exceptionally critical situation at the moment. In east Aleppo city where MSF carries out remote support to medical facilities, an estimated 250,000 people are militarily encircled and a full siege is in operation, starving the population of the basics required for survival, such as food, medical supplies, and fuel to pump water and generate electricity. Furthermore, civilian areas and hospitals are being routinely hit in targeted or indiscriminate bombing and shelling. Attacks by opposition groups occur in west Aleppo which is government controlled but we do not have support programmes there due to a lack of authorisation,  hence we do not have any information on the situation other than what is in the media.

Even those people who manage to flee the fractured front lines or besieged areas and reach the border are finding it increasingly difficult or at times impossible to seek refuge abroad. Border restrictions and closures are forcing people to return to the places in Syria they have fled or to camp out in the desert with no facilities or resources, at risk of violence, disease and hunger. This is the case for example in the berm where 75,000 Syrians are stranded between the Syrian and Jordanian borders.

The bombing of hospitals

Since the siege began in east Aleppo city in July 2016, functioning hospitals have been damaged in over 35 separate attacks. Some hospitals have been hit multiple times and have been forced to close as a result.

Most recently, multiple hospitals were hit by airstrikes from 16 November onwards, one day after airstrikes were relaunched on the opposition-held area of the city. Some hospitals came under attack more than once. Among those hit and taken out of service was a children’s hospital, two key hospitals specialising in surgery and the largest general hospital. The paediatric hospital that was hit was the only specialised hospital for children in the besieged area. Hospital staff managed to move children, including premature babies, from cots and incubators to the basement of the building to shelter from the bombing. Both hospitals that were hit are supported by MSF, among other organisations.

Outside east Aleppo, hospitals supported by MSF have also been hit by bombing or shelling. Recent examples include:

• In one week in October, four MSF-supported hospitals around Damascus were bombed or shelled.
• 18 October - Eman specialty hospital in Idlib governorate was hit in an airstrike that injured four medical staff and lead to the full suspension of the hospital's activities. The hospital provided services for a population of 35,000, including 25,000 internally displaced people.
• 3 November - Al Baghdad hospital in Aleppo governorate was hit by an aitrstrike. While no casualties were reported, the services were partially suspended, affecting around 120,000 people.
• 11 November - An MSF-supported hospital in Hama governorate was hit and heavily damaged in an airstrike, leaving the hospital non-operational. The hospital provided stabilisation, maternity and surgical services, antenatal care, and had an inpatient and outpatient department. It catered to a host population of around 16,600 people, including 1,600 internally displaced people.

MSF projects in Syria

Aleppo governorate

For information on the situation in east Aleppo city, where people are suffering the consequences of the siege and the ceaseless targeted and indiscriminate bombing, see the latest MSF updates.

In Azaz district, MSF runs a 32-bed hospital (Al Salamah hospital) which has an emergency room and also offers a wide range of services including outpatient and inpatient consultations, surgical care, and maternity and additional support services (pharmacy, laboratory, X-ray, etc). In addition, MSF teams can refer patients to other structures in Azaz district or in Turkey if they cannot be treated in the MSF hospital.

The number of internally displaced people in the area has significantly increased since last year, and this had led to a 45 per cent increase in the number of consultations and admissions to our hospital.

Between January and August 2016, staff at the Al Salamah hospital undertook 33,000 outpatient consultations, 1,765 inpatient consultations, 19,506 emergency room consultations and 1,214 surgical interventions.

During the first few months of the year, MSF assisted new internally displaced people arriving in Azaz district, both in formal camps and informal provisional settlements. Non-food items and hygiene kits were distributed to 4,345 families (26,070 people) and tents were handed out to 1,330 families. A water and sanitation programme was also implemented to improve living conditions in one of the informal settlements east of Azaz town.

In June, MSF launched a vaccination support programme, with the objective of implementing regular vaccination activities in the northern districts of Aleppo governorate targeting pregnant women and children under five.

Ein Al Arab/Kobane

In this area of northern Syria, MSF has worked alongside the local health administration since March 2015 to re-establish basic health facilities, provide outpatient health services, re-establish vaccination services and implement psychological support programmes throughout the area. Up until July 2016, there had been more than 50,000 outpatient consultations, over 8,000 emergency room consultations, and almost 2,000 inpatient admissions in MSF-supported structures in the area.

With shifting front lines and an offensive on Menbij by an armed group named the Syrian Democratic Forces (SDF; coalition of different groups in Syria), the number of civilians fleeing their home towards the areas surrounding the Euphrates River increased. 

Both internally displaced Syrians and the host communities are in urgent need of humanitarian assistance. MSF scaled-up its support to local health authorities in the region, and following an outbreak of measles supported the implementation of a ring vaccination campaign in the area east of the Euphrates River in northeastern Aleppo governorate. Over 2,780 children were rapidly vaccinated against measles in communities that were suffering from the consequences of war and ground offensives. Local health response teams simultaneously conducted an emergency food distribution and screened all children who passed through the vaccination campaign for acute malnutrition.

Idlib governorate

In Atmeh in northwest Syria, close to Bab al Hawa border, MSF runs a 15-bed burns hospital staffed by Syrian nationals and supported by an international team based in southern Turkey. The facility began as a trauma centre in 2012 but as needs for specialised burns treatment were identified, it shifted its focus towards this service. Burns patients can receive surgery, skin grafts, have their dressings changed and benefit from physiotherapy. The facility also treats emergency cases in its emergency room. Mental health support and outpatient consultations are also provided. In addition, MSF administers vaccines, and undertakes health education and disease surveillance activities in 180 camps hosting around 165,000 internally displaced people around Atmeh.  A referral system has also been put in place by MSF to transfer patients in need of more specialised treatment to Turkey.

In the first half of 2016, the MSF team in Atmeh burns hospital saw over 6,000 patients in the emergency room, and performed more than 630 major surgeries. During the same period, more than 250 patients were admitted to the inpatient department, and around 240 were transferred to Turkey for further treatment. In the camps for internally displaced people, MSF teams provided more than 81,500 doses of vaccines to children under three.

Hasakah governorate

In addition to the devastation caused by more than five years of war, the general situation in northeast Syria has deteriorated even further due to regular military confrontations between various armed groups, aggravated by more recent tensions with neighboring countries.

Although the border with Iraq has been closed to people crossing since March 2016, movement of populations and goods is allowed intermittently.  

While the region has not experienced the scale of the conflict seen in other areas in Syria, there are significant medical and humanitarian needs.

Since 2013, MSF teams have been offering primary healthcare services through two primary health centres and a maternity clinic, with a particular focus on mother and child care, and chronic diseases. These services are available to both internally displaced people and the host community.

From 1 January to 30 June 2016, MSF teams provided over 24,500 general consultations, including 11,700 for chronic diseases, 4,304 for children under the age of five, and more than 3,200 reproductive health consultations. The teams also assisted an average of 170 deliveries each month. MSF is currently working on opening two additional primary health centres in the governorate.

Remote support to medical facilities nationwide

Since 2011, MSF has been supporting a growing number of medical structures in some of the most conflict-affected areas of Syria, and in areas where MSF  does not have direct access to patients. A particular emphasis has been placed on supporting facilities situated in areas under siege.

MSF runs programmes of active regular support to 70 medical structures, which vary from small rural health posts to full hospitals in urban areas. The supported structures are located throughout much of the country, including in the governorates of Deraa, Hama, Homs, Idlib and rural Rif Damascus. Developed in close collaboration with Syrian medical networks,  and mostly run from neighbouring countries, the support projects run by MSF consist of donations of essential medical equipment and relief materials, distance training for staff inside Syria, support for ambulance services, as well as financial support to cover the facilities' running costs. MSF support is tailored based on needs and on the capacity of other agencies to support the health facilities inside Syria. As such, some facilities rely solely on MSF support, while others receive partial support from other agencies (either international or local). Support levels range from almost 100 per cent MSF-supported through to 50 or 60 per cent MSF-supported..

A further 80 facilities are supported in an ad hoc manner based on specific requests from the facilities, such as emergency donations of medical supplies provided at times of acute need, for example mass casualty influxes.

MSF's medical support programme has increasingly focused on besieged areas, where the medical situation is particularly dire.

Many of these medical facilities have come under such consistent bombardment or shelling that their infrastructure has been catastrophically degraded. Over the past five years many medical staff have been killed or wounded, leaving a chronic shortage of well-trained personnel. The very few humanitarian convoys that have been allowed into some of these areas often have essential medical items removed before reaching their destination, further reducing the medical services that can be offered to these communities. And when patients are severely wounded or sick and need care that cannot be provided in the besieged areas, medical evacuations to properly equipped hospitals are usually denied – even the few medical evacuations that are permitted can take days or weeks to negotiate and organise.

MSF in neighbouring countries

Jordan

Jordan is host to around 629,000 registered refugees, and a roughly equal number are estimated to be living in the country unregistered. Access to free healthcare for refugees living outside the camps in Jordan was stopped in October 2014, creating further difficulties. To support the health burden created by these large numbers, MSF has established a number of health projects where teams undertake surgical interventions, treat non-communicable diseases (NCDs), and provide maternal, child health and mental health services.

Amman

The reconstructive surgery project in Amman was established in 2006 to offer orthopaedic, maxillofacial and plastic surgery, as well as physiotherapy and psychosocial support to victims of violence in the region. As the conflict in neighbouring Syria escalated, the number of Syrian patients increased and more than 50 per cent of the patients in the hospital are currently Syrian. In August 2015, project moved into a newly renovated structure. The move is intended to improve the quality of the medical services offered to patients. Since it opened nine years ago, the hospital has admitted more than 3,700 people and teams have conducted 8,238 surgeries.

Al Ramtha

For the last three years, the emergency surgical programme inside the Al Ramtha government hospital has been offering life-saving trauma surgery for patients injured in the Syrian conflict. Just five kilometres from the Syrian border the project has seen more than 2,400 Syrian war-wounded patients arrive at its emergency room. Around 75 per cent of patients were suffering from polytrauma resulting from blast injuries. Around 90 per cent of all war-wounded patients who come across the border from Syria  are initially seen in the MSF project in Al Ramtha.

Following the closure of the Jordan and Syria border due to a car bomb attack in an area referred to as 'the Berm' in June 2016, only two war-wounded Syrians have arrived at the emergency room.

In March 2016, MSF opened a private NCD clinic in Ramtha city, providing care to Syrian refugees and vulnerable Jordanians. Currently, 1,500 patients are under treatment: around 75 per cent are Syrian and 25 per cent Jordanian. The main diseases treated are hypertension, diabetes, cardiovascular disease, asthma, and chronic obstructive pulmonary disease. The clinic also offers mental health services for NCD patients, and home-based care. Health promotion activities are carried out by MSF community health workers.

Turra, Sahel Houran, Ramtha

In September 2016, MSF started offering free primary healthcare to Syrian refugees and vulnerable Jordanians in the comprehensive primary healthcare center in Turra, Sahel Houran, Ramtha. There are outpatient services, maternal health services such as ante- and postnatal care, and mental health services. Health education is also undertaken.

Zaatari refugee camp

MSF has a 40-bed post-operative care facility in Zaatari refugee camp, which offers post-injury treatment as well as mental health activities and physical therapy sessions. In July 2016, MFS opened a new child-friendly space within the project as part of the mental health activities provided to Syrian war-wounded children in collaboration with other international organisations. Between January and July 2016, over 620 patients received medical treatment at the facility and over 690 psychosocial support sessions were conducted.

After the Jordanian government closed its northwestern border with Syria on 21 June 2016, the number of war-wounded has decreased significantly as they are being denied access to Jordan. Should the situation at the borders remain unchanged, MSF fears that its ongoing programmes in Jordan which address the medical needs of war-wounded Syrians could be forced to close.

Irbid

Following assessments in 2013, MSF established a maternal and child health project in Irbid, close to the border with Syria. The area is home to tens of thousands of Syrian refugees living outside the refugee camps, and these people have difficulty accessing the care they need. Needs for maternal and child care increased at the end of 2014, when Jordanian authorities announced that all Syrian refugees, whether registered or not, would have to pay for Ministry of Health services. In the first quarter of 2015, the project was upgraded to be able to manage complicated deliveries and provide caesarean sections. An intensive care unit was also established.

MSF also has two clinics in Irbid governorate treating Syrians and vulnerable Jordanians who suffer from NCDs. The first clinic, operated in partnership with the Jordanian Ministry of Health, opened in December 2014 and the second, run with the Arabian Medical Relief Society, a local NGO, opened in April 2015. In August 2015, MSF launched the home visit programme – 10 kilometre radius from the town centre – to reach patients who can't access the two clinics due to medical conditions and/or a disability. The majority of patients in both clinics are treated for hypertension, diabetes and asthma. By the end of July 2016, there were 4,540 patients under treatment in the two clinics. MSF also offers psychosocial support and counselling.

The berm: the Syrian–Jordan border

More than 75,000 Syrians are stranded between Syria and Jordan in the northeast of the country. MSF operated a mobile health clinic offering primary healthcare in the berm/Rukban area for 23 days starting on 16 May 2016. Services were provided in trucks, and prioritised children under five as well as pregnant women. MSF also managed referrals in collaboration with the Royal Medical Services, and conducted over 3,500 consultations (more than 200 malnourished children, 10 severely; 500 pregnant women; one baby delivered; three successful emergency medical referrals). After the car bomb attack on the Jordanian border base on 21 June 2016, access to the border was stopped and humanitarian assistance was not provided beyond limited access to water and food.

As of 23 November, UN agencies were allowed to resume their humanitarian aid to the berm. MSF welcomes the resumption of aid and hopes that it will continue to be provided in a regular and sustained manner. However, we are questioning medical aid delivery through the current set-up in the area, as the triage of medical cases should be carried out or overseen by qualified medical professionals. To this end, MSF continues to negotiate for direct access to Syrians at the berm, and reaffirms/reiterates that provision of independent quality medical care should be provided inside the berm.

Lebanon

Registration  problems and deterrence 

The situation in Lebanon remains highly volatile. The presence of over 1.4 million Syrian refugees is putting considerable strain on public services and is exacerbating tensions in the country.

Since December 2014, measures put in place by the government (such as costly visa requirements for Syrian refugees) have reduced the number of newcomers or registered Syrians in Lebanon, who now represent approximately 30 per cent of the Lebanese population.

As of 6 May 2015, the UNHCR suspended new registrations of refugees in Lebanon, in-line with a request by the Lebanese government. Accordingly, individuals awaiting registration are no longer included in the official figures for refugees in Lebanon. Moreover, the costly measures put in place by the Lebanese government for the renewal of documents for refugees deter Syrian refugees from doing so. Therefore, the number of non-documented refuges in Lebanon has increased.

Humanitarian situation

Living conditions are precarious, with increasing numbers of refugees residing in informal tented settlements and unsuitable shelters. The main health concerns are access to primary and secondary healthcare, safe deliveries, mental health and access to chronic disease medications.

Increase in MSF medical activities for refugees

In 2015, MSF provided 305,150 primary healthcare consultations for Syrian refugees in Lebanon, compared to 194,427 for the whole of 2014 and 96,320 for the whole of 2013. Between 1 January and 30 June 2016, MSF provided 170,000 primary health care consultations in its clinics across Lebanon.

Bekaa Valley

In the Bekaa Valley, where the majority of refugees have settled, MSF began providing primary healthcare in March 2012. This continues today and includes treatment of acute illness, chronic diseases and a comprehensive reproductive health package, through four clinics in Hermel, Arsal, Baalbek and Majdal Anjar. These services are provided for Syrian refugees irrespective of registration, as well as for vulnerable Lebanese. In addition to the reproductive health package offered in the four clinics, mental health support as well as health promotion services are also offered. MSF runs sessions specifically for women and girls, where they can consult a female doctor and/or midwife, as well as women-only sessions where women-specific health issues are discussed.

In February 2016, MSF opened its third mother and child centre in Majdal Anjar, in central Bekaa, just a few kilometres away from the Syrian border. The centre is open 24/7, and teams assist uncomplicated deliveries. The centre's services are available to more than 15,000 women who otherwise have no access to free and safe delivery.

The north and Akkar governorates

The north of Lebanon also hosts a large number of Syrians (252,450 people; UNHCR, October 2016). MSF runs five primary healthcare centres in the region, offering free health services to Syrian refugees and vulnerable Lebanese in Akkar and Tripoli governorates. MSF services include providing treatment for acute cases, chronic diseases, a comprehensive reproductive health package, mental health counselling and vaccinations, in addition to health promotion activities.

In Tripoli, MSF has worked in Dar al-Zahraa hospital since February 2012, providing basic healthcare, treatment for chronic diseases, reproductive healthcare and vaccinations for Syrian refugees and vulnerable Lebanese. MSF has also been working in Al-Zahraa dispensary in Jabal Mohsen district since November 2012, and Al-Dawa dispensary in Bab al-Tabbaneh district since April 2013, providing primary healthcare, including treatment for acute diseases, vaccinations and reproductive health. In Jabal Mohsen, MSF provides support during outbreaks of violence to stabilise patients before they are transferred to hospital.

In Akkar governorate in April 2015, MSF opened another primary healthcare clinic in Abde, north of Tripoli. The clinic provides primary healthcare, including care for acute conditions and NCDs, as well as sexual and reproductive healthcare. It also offers mental health and health promotion activities, as well as vaccinations. In September 2016, MSF opened a health centre in Wadi Khaled offering treatment for NCDs and mental health counselling.

Palestinian refugees from Syria

Before the war began, Syria was home to approximately 500,000 Palestinian refugees, some of whom were born and raised in the country. Palestinian refugee camps inside Syria, including in Aleppo, Daraa, and the Yarmouk camp in south Damascus, have come under attack and siege, resulting in numerous fatalities and injuries. By April 2014 over 3,070 Palestinians from Syria had registered in Lebanon with UNRWA and 13,836 had sought support from UNRWA in Jordan.

Since June 2013, primary healthcare consultations have been provided at Human Call Hospital in Ein-al-Helweh camp, the largest Palestinian refugee camp in Lebanon. It is currently home to around 100,000 people.

In the Shatila Palestinian refugee camp, which is only 4 kilometres away from downtown Beirut, over 30,000 refugees (Syrians, Palestinians, Palestinians from Syria and minorities) live in deplorable conditions. Since September 2013, to deal with the increasing health needs in the south Beirut area, MSF has been running a primary health centre and a women's health centre in Shatila. The project is intended primarily for Syrian refugees, but is open to Palestinians who have fled from Syria and other vulnerable communities living in south Beirut. The focus is on unregistered refugees who are not eligible for official assistance, or for registered refugees with emergency surgical needs that fall outside the UNHCR's shortlist of eligible injuries. The maternity unit provides care during pregnancy and simple delivery, with referrals for complicated deliveries to surrounding hospitals. Moreover, the newly expanded primary health clinic deals with postnatal care, paediatrics and chronic diseases for adults and children. Mental health consultations are also provided in both facilities and more than 6,500 patients are seen in total at both centres each month.

In Burj al-Barajneh refugee camp, also located in the southern suburbs of Beirut, MSF is expanding its work by opening a new health centre to provide sexual and reproductive health services, including the treatment of sexually transmitted diseases, mental health and also to provide health promotion activities for the local population. In May 2016, the MSF health centre in Burj al-Barajneh launched a home-based care programme for patients with chronic diseases who suffer from mobility problems.

Iraq

The Kurdish Region hosts the vast majority of the 251,499 Syrian refugees currently in Iraq (UNHCR, July 2015), but with the current turmoil in the country the burden on the region is increasingly high. In light of the overwhelming crisis, some international humanitarian organisations are scaling down their assistance to Syrian refugees in the country. Over the past year, the spread of violence across Iraq has led some Syrian refugees to return to Syria while tens of thousands of Iraqi nationals crossed into Syria in August 2014 before crossing back into safer areas of Iraq.

Domiz

The population in Domiz refugee camp (Dohuk governorate) has significantly reduced over the past year due to large movements of people. Today, the camp's population is estimated to be around 38,392 (UNCHR, October 2016).

From May 2012 to October 2015, MSF was the main provider of health services to Syrian refugees in Domiz camp, including primary health care, sexual and reproductive healthcare, care for chronic diseases and mental health assistance. Since August 2014, MSF has been running a maternity unit inside the camp, and today MSF teams focus on providing sexual and reproductive healthcare through this unit. Teams assist an average of 85 deliveries per month and ensure the referral of complicated cases to Dohuk hospital

In October, after three years of activities, MSF teams handed over the general health care and mental health consultations to the local authorities. The treatment of patients with chronic diseases was handed over in June 2016 to the Department of Health.

Erbil

MSF provides mental health services in two refugee camps in Erbil governorate – Kawargosk camp and Darashakran camp.

Turkey

Turkey hosts more than 2.5 million Syrian refugees. In Kilis, MSF is working in partnership with Citizens' Assembly to provide primary healthcare and mental health psychosocial support for Syrian refugees. Between 1 January and 31 August, the primary health care component of the project provided 21,153 outpatient consultations. In the mental health programme, 2,648 individual psychological sessions were conducted, and 1,804 group counselling or home visit sessions with undertaken by trained community health workers.

In Sanliurfa province, MSF works in partnership with two Turkish NGOs (Support to Life  and International Blue Crescent Foundation) to provide mental health services. Through this partnership, assistance is also provided to  refugees arriving from Kobane and Tal Abyad, with food and hygiene kit distributions, and improvement of water and sanitation infrastructure in the camps.

MSF worked in Akcakale transit camp from November 2015 until it closed in May 2016. The Akcakale camp was hosting 4,000 refugees, and approximately 300 were voluntarily relocated to other camps while the rest preferred to live outside. MSF distributed hygiene kits to those who decided to live outside camps in the outskirts of Akcakale town.

MSF is providing financial and technical support to partner agency Hayata Destek (Support to Life) in Şanlıurfa province. A program to provide mental healthcare and psychosocial support to Syrian refugees in Şanlıurfa is ongoing. MSF also provides financial and technical support to International Blue Crescent Relief and Development Foundation to support their provision of mental healthcare and psychosocial support activities for Syrian refugees through a community centre in Akçakale. 

In Gaziantep, the Voluntary Health Center for People under Temporary Protection opened in December 2015 co-lead by MSF and Physicians Across Continents.  The centre provides sexual and reproductive healthcare and outpatient consultations to women and children. The MSF-run sexual and reproductive healthcare activities at the clinic ceased in April 2016, but MSF continues to provide consultations to its patients by supporting the Primary Health Care Association, a Syrian medical facility based in Gaziantep.