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Airstrikes hit an MSF-supported hospital in Dara’a governorate.

"MSF adapts to respond to the needs of a war-afflicted population"

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Omar Obeid has been working as Project Coordinator for an MSF South Syria project, managing it remotely for the last 14 months. Over the past few weeks, fighting has intensified in southern Syria, as opposing forces contest to retake the city of Dara’a. As bombings and aerial attacks in Eastern Dara’a increased, hospitals and medical structures in the area have been forced to announce their closure to avoid being targeted.  International medical humanitarian organisation Médecins Sans Frontières supports a number of hospitals in South Syria, however, the current capacity of field hospitals and health facilities in southern Syria is ever shrinking as most facilities are unable to respond to the specialised surgical needs of war-wounded Syrians. But what are the needs on the ground? What are the challenges MSF and the humanitarian system is facing in responding to the raging battles in South Syria?  Obeid sheds some light on the humanitarian situation in the area.

What is happening in the south of Syria? What does the humanitarian situation look like?

Since mid-February, mostly after the Astana peace talks, Dara’a city has been practically emptied out. At least 25,000 to 35,000 people have been displaced, mostly due to the intensified fighting and bombing in Dara’a and the hostilities in the nearby Yarmouk valley. Those who have fled have taken refuge in the farmlands south-east of Dara’a city with very little belongings or sources of support. From the Yarmouk valley to the west around the area of Ash-Shajara, roughly 2,000 displaced families— about 8,000-10,000 people - have been displaced.  

We are talking about a war where the civilian population itself is targeted. Their homes, schools, markets, hospitals and other medical structures are predictably bombed, especially when the fighting escalates. A lot of displaced families go to households in neighbouring towns where they are hosted by other families. But because people have been displaced since last year when fighting erupted in the areas of Sheikh Miskin and Atman, and a further displacement of people occurred from Dael and Ibtaa earlier this year, the living situation of the population is already under pressure. Thus now, we start seeing people sleeping in the streets and outside in the farmland.  Makeshift tents that can barely meet the shelter, water or hygiene needs of families have become a common occurrence too.

What are the needs on the ground with the fighting in southern Syria?

With the continuous fighting, the biggest concern at the moment is the protection of the vulnerable population and their needs for proper shelter.  There are few formal camps in the Dara’a area and despite concerted efforts, the needs for proper shelter and tents for the displaced people have still not been met. That is why we still find so many families in the streets and on farmlands putting the lives of thousands of people  at risk.

Many roads have also been cut off or partially closed because of the conflict and the danger in using them, including the road from Western Dara’a to Eastern Dara’a. These road closures result in major problems in accessing assistance.

In terms of health needs, although MSF and other organisations have sought to anticipate periods of increased violence, hospitals and medical facilities in the south as a whole continue to be understaffed and underfunded.  Most hospitals are not receiving enough supplies and medications, nor funding for salaries and running costs to meet their needs.  There are still very large gaps in all aspects of healthcare—whether it’s secondary and tertiary healthcare, routine vaccination, mental health, chronic diseases, and reproductive health.

The lack of access to quality health care in South Syria, as well as along the border with Jordan, also means war-wounded Syrians have difficulty accessing specialised surgical care such as multiple trauma injuries and highly complex interventions. In March, there was an increase in the amount of war-wounded allowed into Jordan to receive such care, but it is still far from meeting the sheer scale of the needs on the ground.

Faced with those dire conditions in south Syria, what is MSF doing? What are the main challenges? 
The frail situation in Syria as a result of the war— including bombings and the ever-present threat of attacks on hospitals—not only denies the population access to medical facilities but also affects the scope and effectiveness of the medical care that can be provided. While MSF has been able to find ways of providing healthcare in many parts of the country, including in south Syria, this has not been without significant challenges.

Currently, MSF supports a few hospital structures in southern Syria, including a blood bank, and remote technical support for a hospital with an operating theatre, emergency unit, maternal health unit, and inpatient care department. MSF’s support include donations of essential medical equipment and relief materials, training for staff inside Syria, and other means of support to keep the facilities afloat in these dire conditions. Support is tailored based on needs and on the capacity of other agencies to provide backing to the health facilities inside Syria. As such, some facilities rely solely on MSF support, while others receive partial support from other international or local agencies.

In the past six weeks, Syria´s Dara´a Governorate has seen a surge of 30,000 internally displaced people as fighting continues in the southern part of the country.  We distributed relief items in two areas, both are on the frontlines of the conflict. MSF responded with an emergency distribution of 893 kits of essential relief items (including hygiene kits, clothes, cooking utensils, blankets and mattresses). As the clashes in Dara’a had intensified, MSF had donated a number of these kits to Dara’a city and Nassib. The road between the east and west of Dara’a governorate may be potentially cut off—so as a response MSF plans to support a blood bank referral centre in a nearby area. We have also pre-positioned emergency and surgery kits in some health facilities.

But the fact remains that we are not physically there. MSF has long made proximity to patients, and the direct implementation of medical care, a key tenant of its interventions around the world. The lack of proximity makes us less well-positioned to respond to emergencies, given all the constraints such as shifting frontlines, administrative and bureaucratic hurdles, violence along access routes, and general safety and security concerns. More recently, there have been a lot of restrictions on the supplies of any of the organisations permitted to go into Syria.  There are constant supply shortages. The closure of the border has also made it difficult to respond quickly to emergencies and the increased violence. 

The lack of proximity also makes the provision of quality medical care very challenging. It is not only difficult to identify the gaps and areas where the quality can be improved, it also makes oversight of the current quality of healthcare provision difficult—especially when we don’t have the right resources and stock readily available.

We also need to keep in mind that we are working in an area where medical structures and hospitals specifically are under attack, and we have to be careful with the interventions we are doing so as to try to offer proper medical care without increasing the risk to beneficiaries and to our staff.  Firstly, it is difficult to find medical staff in general—they are underpaid and very overworked. Almost all the hospitals in southern Syria have been hit at least once, if not repeatedly, since the conflict started. Here we are struggling to get to the bottom of the question of protection of not only our own staff but also the hospitals’. Moreover, we have to balance the care and services we provide with the increased risk of patients coming to structures that are targeted.

What are some of the additional challenges of operating an MSF project from a remote setting?
It is always challenging to work from a remote setting, and there is some hesitation for remote assistance shared within MSF and beyond.  We are constantly relying on the observations of other humanitarian actors or the staff we have inside Syria in trying to assess the needs.  There is a lot more coordination required between us and the actors to try to understand the reality on the ground and understand what other organisations are doing, since we are not physically there to witness it in person.  This fragments the response as a whole.  Despite the fact that there are enough actors operating inside a relatively small zone in south Syria, the response is still insufficient and funding limitations persist. Due to the lack of coordination, the different priorities of the different actors, and the different systems of each organisation, the aid response in Syria is fragmented.

Distance also means you cannot see what the conditions are and what needs to be improved in terms of quality of healthcare at the facilities. There are a lot of challenges as well when you don’t have a chance to meet and work closely in person with those who are doing all the hard work.  Training and capacity building is a huge issue, alongside the difficulties of managing staff remotely. Moreover, you don’t have the chance to develop a personal relationship in the same way, and it becomes harder to direct and work through some of the problems that we are constantly facing.

MSF directly operates four health facilities in northern Syria and provides support to more than 150 health facilities in the country.