Syria: Speaking out on siege and starvation in Madaya

This case study illustrates the article: "No eyes on the ground. MSF’s dilemmas of using third party medical data and patient testimonies"

In January 2016, the UN reported ‘credible reports of hunger and starvation’ in Madaya, a small besieged area close to the border with Lebanon. Medics from a local clinic, believed to be the only one functioning in the area and supported by MSF since 2014, provided the organisation with figures of deaths caused by starvation spanning a period from 1 to 29 December. They also provided some photographic evidence of severely malnourished children to illustrate the situation.

Despite the UN report on the situation, the desperate situation in Madaya continued to go largely unnoticed. Negotiations in Damascus between the ICRC, the UN and the government for permission to send food and medicines remained unresolved.

Concrete figures could have galvanised the international media around the story and created huge pressure on the negotiation process involving multiple parties and nations. Getting the tone, facts or timing wrong could have made the situation in Madaya worse, not better. But the legitimacy of MSF to speak on the situation as a relevant medical actor could have been questioned as, despite regular contacts for medical advice, the last time MSF was able to support the clinic was in August 2015.

Finally, MSF decided to issue a press release on 7 January, breaking the news that 23 people, including six babies under one year old, had died of starvation. This data came from two lists of patients shared by the health centre: one with the dead, the other with the sick and malnourished. These lists, the photos and MSF’s trust in the facility’s medics were the fragile and only evidence available. Although imperfect, we decided – after long internal discussions – that the information was sufficient to launch a public alert in an attempt to accelerate ongoing negotiations.

It was decided not to use the photographs of malnourished patients supplied by the clinic. They would have amplified the message considerably but there was no way to secure the consent of the patients or verify the authenticity of these pictures. The raw figures alone resonated with the media and the story of starvation in Madaya received considerable attention, exposing the brutality of besiegement tactics.

In the days that followed, agreements were reached finally in Damascus and convoys of food and medicine were allowed into the enclave, accompanied by international staff from the ICRC and the United Nations. Although these visits confirmed that a significant number of people had indeed suffered from malnutrition, they also exposed some of the weaknesses of MSF reliance on ‘underground’ clinics only.

Contrary to MSF’s belief, the supported clinic was not the only one in town, and initial supplies and medical evacuations organised by the UN and ICRC convoys were in collaboration with the Ministry of Health-supported clinic and two doctors that MSF had no contact or working relations with. This left MSF looking exposed when, in the days following the highly publicised arrival of the first aid convoys, we could not answer questions related to the medical supplies that had arrived, or medical evacuations that were permitted, despite the fact that these two issues were the main demands in the MSF communication.