As the conflict in Syria approaches its 6th year, the humanitarian and medical toll of the violence remains appalling. Millions of people have been internally displaced, or have sought refuge abroad. Millions more are trapped in communities that are under siege or hemmed in by the closed borders of neighbouring countries. These countries, already overwhelmed by the numbers of Syrians seeking protection, have increasingly introduced restrictions on entry for new arrivals.

Meanwhile the level of violence inside the country shows no signs of abating. Death and injury is a daily reality. The year 2015 saw an increased number of countries engaging their military and entering the war. Russia intervened in September on the invitation of the Syrian government, with significant use of its air force, while France and the UK extended their air campaigns under the US led coalition from Iraq to Syria in September and December. This situation is unprecedented, as four of the five permanent members of the UN Security Council are now actively engaged in hostilities in the Syrian conflict.

This report aims to present a documented analysis of the medical and humanitarian consequences of the intensification of the military campaign in 2015, based on medical reports and data from 70 clinics and hospitals in Syria supported by Médecins Sans Frontières/Doctors Without Borders (MSF).

Context

• The Syrian conflict is approaching its sixth year, and humanitarian and medical toll from the violence remains appalling, with no signs of abating.
• In 2015, there has been an increase of the number of countries engaged in military conflict in Syria, notably the Russian intervention, as well as the expansion of the French and British air campaign with the US-led coalition. 4 out of 5 of the permanent UNSC members are participating in the conflict.
• Since 2011, MSF has attempted to gain official access by the Syrian authorities to work in the country, however to date, this has been unsuccessful. The result is the unprecedented model of lending indirect support to medical actors within Syria, especially in 'hard-to-reach'/'besieged areas'.
• The data complied is speculated to be around 70% of the total numbers of war-wounded and war-dead in besieged areas (considering that MSF supports 35 out of 50 facilities in such areas).
• The data of non-besieged is derived from 45 facilities in the northern and western parts of Syria. The number of facilities fluctuates due to the attacks. 
• The data on mass casualties are received from two sources: mass casualty influx reports from MSF-regularly supported facilities and crosschecked with non-regularly MSF-supported facilities. These injuries/dead are mainly from aerial attacks, with some areas resulting from either aerial or shelling.
   

Key Data Findings

• On war-wounded and war-dead in the Damascus region: out of 66 communities identified in the Damascus region – with a combined estimated population of 1.45 million – and derived from 35 health facilities supported by MSF: 93,162 were treated, of whom 36,068 were women and children (child defined as under the age of 15). MSF recorded 4,634 war-dead of which 1,420 (31%) were women and children. There has been a decrease on a month by month basis due to the shift of conflict to the West and North of Syria.
• On war-wounded and war-dead in northern and western Syria: MSF regularly supports 45 medical facilities, of which an average of 34 contributed medical data (12 of which are in besieged zones). The data shows: 61,485 war-wounded treated, 10,473 (17%) were children under five.
• On mass-casualty: 74 mass casualty incidents were recorded. They account for 3,978 wounded treated, with 1,252 (31%) women and children; 770 dead, 228 were women and children. East Ghouta, in August alone, recorded 28 individual mass casualty events, which accounted for 840 wounded, 367 of which are women and children and 144 dead, 48 women and children. After October, there has been an increase of mass casualty events in north and western Syria, with October marking 17 mass casualty events (575 wounded, 220 of which are women and children; 120 dead, of which 53 women and children).
• Attacks on medical facilities and deaths of medical staff: The data also shows a total of 94 aerial and shelling attacks of hit MSF-supported facilities, with 12 cases leading to total destruction (first spike recorded in May and June, followed by October), as well as a total of 81 medical staff killed. Note: MSF supports only a fraction of the total medical facilities in Syria.
• Double-tap attacks: Data shows that there is numerous cases of 'double-tap' attacks (ie a second attack that happens between 20-60 mins after the first) – This is recorded by time in specific cases.

In total, MSF-supported facilities alone have recorded 7,009 dead, 154,647 wounded; 30-40 % being women and children. In besieged zones in Damascus region: MSF recorded 1,400 dead and more than 36,000 wounded.  

MSF's Message

• MSF urgently calls for all attacks on civilian targets and infrastructure to end
• MSF specifically calls for protection and respect of medical facilities, and end all attacks on them
• MSF calls for full humanitarian access to all besieged zones and unhindered movement for medical evacuations, supplies, and medical staff.
• MSF specifically appeals to 4 of the UNSC permanent members to respect their own resolutions, and to pressure their allies to implement them.