What was an already dismal situation for millions trapped by conflict in Syria at the beginning of 2015 deteriorated further throughout the year, pushing hundreds of thousands of people to make the hard decision to make a dangerous and sometimes deadly crossing into Europe.

The scale of death, injury and displacement from the conflict that began following the Arab Spring protests of 2011, is unimaginable. The United Nations estimated at the beginning of 2015 that 220,000 people had been killed, but other monitoring groups put the death toll much higher. An estimated four million people have fled outside the country with the vast majority fleeing to Lebanon, Turkey, Jordan and Iraq. Hundreds of thousands of people are living in besieged areas inside the country, with extremely limited access to healthcare.

With massive unmet needs inside Syria, MSF should be running some of the biggest operations in its history, but the scale of the violence and the fast moving nature of the conflict means that the work MSF inside Syria is limited. Following the abduction and release of MSF staff in 2014, the extremely difficult decision was taken to close projects and stop support activities in areas controlled by the Islamic State (IS) group. MSF has sought high-level assurances from the leadership of the IS group that staff and patients will not be harmed, but these assurances have not been forthcoming which means that large swathes of the country  - and the people living there - are out of our reach. MSF has also been unable to date to receive permission from the government of Syria to work in areas it controls, again meaning millions of people are out of reach of hands-on assistance from any external aid provider.

Despite these significant constraints, MSF continues to operate medical facilities inside Syria, as well as supporting directly more than 150 medical structures throughout the country. In neighbouring countries, throughout 2015 activities have been scaled up and additional projects have been opened, but still the needs remain enormous.

MSF in Syria

Aleppo governorate The impact of the conflict in Aleppo governorate in the north west of Syria, is severe and has deteriorated significantly through 2015. The population in this northern governorate lives through indiscriminate violence as well as the deliberate targeting of what remains of the all but destroyed health system. Massive displacements affect large segments of the population and Aleppo is one of the main corridors for Syrians attempting to flee the war.

A 27-bed MSF hospital run by Syrian staff in the region offers a wide range of services including outpatient and inpatient consultations, emergency room, surgical care and maternity. In addition the MSF team provides mental health care, and can refer patients to other structures if they cannot be treated in the MSF hospital.

January to August 2015 statistics for Aleppo Hospital

• 23,010 outpatient consultations
• 1,069 inpatient consultations
• 11,251 emergency room treatments
• 900 surgeries

Ayn Al Arab / Kobane canton Inside this area on northern Syria, MSF has worked alongside the Kobane Health Administration since March 2015 to re-establish basic health facilities, provide outpatient health services with 11,800 consultations through September, re-establish vaccination services and create psychological support programmes. In August MSF supported the local health authorities in providing measles vaccinations and vitamin A for 5,776 children.

Idlib Governorate

In this governorate, also in the northwest of Syria, MSF runs a 15-bed burns unit, staffed by Syrian nationals and supported by an international team in southern Turkey. The facility began as a trauma centre, but as specific needs for specialised burns treatment were identified, it focussed on this work. Burn patients needing skin grafts, frequent dressings physiotherapy are treated in this centre, as well as treating emergency cases in a small emergency room. In addition, MSF runs activities for people living in camps for Internally displaced people in the area, which host more than 100,000 people. Services offered to these IDPs include disease surveillance and routine vaccinations.

Hasakah Governorate

Hasakah, in northeast Syria, is home to a sizable share of Syria’s Kurdish minority, and for almost a year clashes between various armed groups have been on the rise. The border with Iraq has been closed since the end of September 2013, and since June 2014 it has been open only for Syrian returnees from Iraq. 

In this governorate, MSF runs several medical centres that offer primary health care services with a particular focus on mother and child care, as well as chronic diseases. These services are offered to both IDPs and people from the host communities. Between January and June, MSF provided 18,618 consultations in the clinics it runs and in addition in the maternity clinic supported by MSF in the same period there were 571 deliveries and 196 caesarean sections In addition, MSF has also distributed water, meals, hygiene kits and blankets to people in camps who had been forced to flee violence.

Remote support to medical facilities nationwide

Since 2011, MSF has been supporting a growing number of medical structures in government-held and opposition controlled areas throughout the country, with a particular emphasis on structures in areas under siege. By October 2015 MSF was actively supporting more than 150 medical structures which vary from small rural health posts to full hospitals in urban areas. The supported structures are throughout the country, including in Idlib, Aleppo, Homs, Hama, rural Damascus and in Deraa in the south. Developed in close collaboration with Syrian medical networks and run from neighbouring countries, the support projects run by MSF consist of donations of essential medical equipment and relief material, distance training for staff trapped inside Syria as well as support for ambulance services.

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 free health care for refugees living outside the camps in Jordan was removed in October 2014, creating further difficulties for these people. To support the health burden created by these large numbers, MSF has established a number of health projects that undertake surgery, work on non communicable diseases as well as maternal and child health and mental health.

Amman

In August 2015, the Reconstructive Surgery Project in Amman moved into a new renovated structure in the capital city. The move to the new hospital is intended to improve the quality of the medical services offered to patients in the structure. The project was established in 2006 to offer orthopaedic, maxillofacial and plastic surgery, as well as physiotherapy and psycho social support to victims of violence in the region. As the conflict in neighbouring Syria escalated, the number of Syrian patients increased to the situation currently, where more than 50 per cent of the patients in the hospital are Syrian. Since it began nine years ago, the hospital has admitted more than 3,700 cases and conducted 8,238 surgeries.

Al Ramtha

For the last two 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 1,850 Syrian war wounded patients arrive in its two operating theatres. Around 75 per cent of these patients were suffering from poly trauma resulting from blast injuries and more than 2,900 surgical interventions have been performed on the 864 patients admitted into to the surigical programme run by MSF in the hospital.

Zaatari

As the trauma surgery project in Al Ramtha grew, MSF established a post-operative care facility in Zaatari refugee camp. The unit now has 40 beds and offers post-injury treatment as well as mental health activities and physical therapy sessions. Between January and September 2015, 133 patients received medical treatment at the facility and around 400 psychosocial support sessions were conducted.

Irbid

Following assessments In 2013, MSF established a maternal and child health care project in this northern town, close to the border with Syria. The catchment area for the is home to tens of thousands of Syrian refugees living outside the refugee camps who 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 as well as an intensive care unit.

Lebanon

The situation in Lebanon remains highly volatile. The refugee influx is putting considerable strain on public services and exacerbating tensions in the country. Since December 2014, measures put in place by the Government such as the limitation of entrance in Lebanon for refugees have reduced the number of new refugees arriving in Lebanon. 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 refrain Syrian refugees to renew their documents. With such measures the number of non-documented refugees in Lebanon is only likely to increase. 

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

From January to June 2015, MSF provided 126,048 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.

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

Tripoli, North Lebanon, also hosts a large number of Syrian refugees. MSF has worked in Dar al-Zahraa Hospital since February 2012, providing basic healthcare, treatment for chronic diseases, comprehensive reproductive health package 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 health care, including treatment for acute diseases and reproductive health. In Jabal Mohsen, MSF provides support for light surgery to stabilize patients while waiting for transfers to a hospital during outbreak of violence.

In April 2015, MSF opened a new clinic in Abde, north of Tripoli. The clinic provides primary healthcare, including acute, non-communicable diseases and sexual and reproductive health. It also offers mental health and health promotion activities, as well as vaccinations.

Palestinian Refugees from Syria

Before the March 2011 uprising 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 civilian 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.

In Lebanon, MSF has provided mental health services for Palestinian refugees and vulnerable populations residing in Ein-al-Helweh camp, near Saida, and surrounding areas since April 2011. In June 2015, the project was handed over to UNRWA.

Since June 2013, primary healthcare consultations were also provided at Human Call Hospital in Ein-al-Helweh camp for Syrian refugees and Palestinian refugees from Syria and Palestinians already living in the camp.

Since September 2013, MSF has been working in Beirut’s Shatila camp, where Palestinian refugees have gathered, focusing on primary healthcare, chronic diseases and mental health services. The team has also set up a system for supporting patients with emergency surgical needs, referring them to two hospitals with which MSF has agreements. The project is intended primarily for Palestinians who have fled from Syria, but is not closed to other residents of the camp. 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. On average, the primary healthcare clinic services nearly 2,000 patients per month.  Furthermore, a women’s health centre was established in January 2015, providing various maternity care services for vulnerable women in Lebanon. The centre performs more than 100 deliveries per month. 

In southern Lebanon, MSF is providing primary healthcare, chronic disease and mental health support for refugees in three health centres (Chebaa, Marjayoun, and Klayaa). MSF has gradually been seeing a small increase of Lebanese patients, in addition to servicing Syrian refugees.

Iraq

The Kurdish Region (KRG) has been hosting the vast majority of the 251,499 Syrian refugees currently in Iraq (UNHCR, July 2015), but with the current turmoil in Iraq, the burden on KRG is increasingly high. In light of the overwhelming crisis affecting Iraq today 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 Iraqi have crossed into Syria in August 2014 before entering back into safer areas in Iraq.

Domiz

Since May 2012, MSF has been the main organization providing health services to Syrian refugees in Domiz refugee camp, including primary health care, sexual and reproductive health care, chronic diseases and mental health assistance. MSF also offers emergency services and referrals to Dohuk hospital. Initially set up for 27,000 people, the camp houses today approximately 41,000 Syrian refugees (UNHCR, June 2015). Between January and June 2015 MSF medical teams carried out 63,314 consultations including primary health care and maternal health care. On 4 August 2014, MSF opened a maternity unit and oversaw the delivery of the first child. Since the opening of the facility a year ago there have been on average 100 deliveries per month. From January till June 2015 there were 660 deliveries carried out in the MSF maternity facility.

Erbil

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

Turkey

Turkey hosts more than a million refugees fleeing the conflict. MSF was authorised in June 2015 to work with refugees from the Syrian crisis. In Kilis, a town on the southern border with Syria, the number of refugees (107,000) is higher than that of the host population, (90,000). Between January and August 2015, MSF provided counselling for 2,075 people, and performed 22,860 outpatient department consultations. In Sanliurfa Province MSF works in partnership with two Turkish NGOs to provide ongoing mental health service and responded to refugee influxes from Kobane and Tal Abyad with food and hygiene kit distributions, along with water & sanitation infrastructure in camps.

Syrians fleeing to Europe

The ongoing conflict means that hundreds of thousands of Syrians are prepared to risk their lives to seek refuge in Europe. Initially the main routes were through Egypt, Libya and Turkey and finally by boat to Greece and Italy, and now, new overland routes have also opened. Many of the people taking these dangerous journeys are Syrian, and the welcome they find in Europe can be bitterly hostile.

What is MSF doing to help?

MSF is currently operating two search-and-rescue ships in the Mediterranean:

Bourbon Argos: Launched on 9 May to carry out search and rescue operations in the Mediterranean Sea. The Bourbon Argos has the capacity to carry up to 900 rescued people to land.

Dignity I: Launched on 13 June, Dignity I has a crew of 18 people, which includes medical staff. The 50 metre-long vessel left the port of Barcelona on 13 June and has the capacity to carry 300 people to land.

MY Phoenix: Between 2 May and 23 September 2015, MSF had a team of six people providing post rescue care on board the Phoenix, a search and rescue vessel run by MOAS (Migrant Offshore Aid Station) but funded 50% by MSF. The medical care available ranged from primary care right through to resuscitation and advanced life support. MSF is no longer working on the MY Phoenix. On 22 September MOAS informed MSF that they would cease operations in the Mediterranean Sea. As a result MSF is no longer in partnership with MOAS or working on board the Phoenix.

To date, the three boats have rescued 16,350 people. They have also assisted a further 1,166 others with safe passage to Italy (after they were rescued by other boats) making it a total of 17,516 people assisted by MSF’s teams on the Mediterranean.

Additionally, MSF operates land-based migration projects in five countries.

Tunisia

MSF has been working with fishermen in Zarzis, Tunisia to offer training in search and rescue.

Italy

MSF is working in the first reception centre in Pozzallo (Ragusa province, Sicily) in collaboration with Ministry of Health to provide medical services to migrants, asylum seekers and refugees from the time they arrive and during their stay in the centre. MSF also provides mental healthcare support to people living in reception centres in Ragusa province.

Greece

MSF is providing medical care and distributing relief items to migrants arriving in the Dodecanese islands as well as on Lesbos and the Idomeni border crossing to Macedonia.

Since the beginning of this year, MSF teams in Greece have witnessed a marked increase of arrivals in the Greek islands. The vast majority of the people arriving in Greece come from Syria, Afghanistan and Iraq.

Lesbos - MSF is providing medical consultations, mental health support and distributing relief items. MSF also works on improving water and sanitation in the Kara Tepe and Moria camps and ensures cleaning services. MSF is also offering transportation through buses to new arrivals so they do not need to walk the 7-km distance from arrival points on the north coast to the registration centre in Mitilini.

Idomeni - In Idomeni, close to the border with FYROM (Former Yugoslav Republic of Macedonia), MSF is running mobile clinics and distributing relief items for those who first arrive in Greece and continue crossing the Balkans to go to northern Europe.

Athens - In Athens, MSF launched in October 2014 a project offering medical rehabilitation to asylum seekers and migrants who have been victims of torture, in collaboration with two Greek organizations (the Greek Council for Refugees and Syneirmos/Babel). So far, our team has received a total of 140 patients.

Serbia - MSF teams have been providing medical and mental healthcare and distributing relief items such as hygiene kits, food, survival items, tents, blankets and raincoats to people crossing through Serbia since late 2014.

Croatia - MSF is working in Croatia, in a transit camp near the border with Serbia (at about 15 km from Tovarnik) where refugees spend about a day before being transferred to Hungary. In the camp, which hosts around 5,000 people daily, MSF has opened up a clinic.