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Open letter to all States and non-State actors involved in the conflict

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Following the agreement brokered between the governments of Russia and the United States of America, the international medical humanitarian organisation Médecins Sans Frontières (MSF) calls on these two States to place at the top of their diplomatic agendas the substantial scale up of humanitarian aid to millions of war-affected Syrians.

Given the multiplicity of States and non-State actors involved in the Syrian conflict, it is imperative that the Russian and U.S. governments work with their respective political allies to develop a strategy for facilitating a massive infusion of humanitarian assistance wherever it is needed in Syria.   

To be clear, the call for breaking the deadlock for humanitarian aid should not be interpreted as a call for militarised assistance.  As recognised under international humanitarian law, aid and relief workers must be allowed to move freely to reach those most in need. The Russian and U.S. governments should therefore apply the same level of diplomatic energy to increase humanitarian aid to the millions of victims of violence in Syria as has been brought to secure an agreement about the control of chemical weapons.

Nearly two and half years into the Syrian conflict, the war has killed more than 100,000 people. One quarter of the country’s population has been forced to flee their homes. A further 2.1 million people have fled the country.

The medical system – like the rest of Syrian society – has been under siege during the conflict and is no longer capable of responding to the acute and chronic medical needs of the Syrian population. Hospitals and medical staff have been targeted throughout the war. Of the 91 public hospitals across the country, 55 (60 per cent) have been damaged or have been completely destroyed.   

In many areas, people are too scared to cross front lines to access healthcare, and healthcare workers have been killed, arrested, tortured or threatened. Twenty-two Syrian Arab Red Crescent volunteers have been killed since the beginning of the war. The environment for independent medical aid is becoming even more hostile. One of the latest examples was in early September when a field hospital in al Bab, northern Syria, was bombed by the Syrian air force, killing nine patients and two medical staff. Aid workers are also coming under fire from some opposition groups.   

Before this conflict, Syria had a well-functioning health system with advanced medical expertise and its own pharmaceutical industry. But today, those resources are almost completely depleted, on all sides of the front lines. Essential medicines are in short supply as a result of the collapse of the pharmaceutical industry or indirectly from international sanctions imposed on Syria. The effective blockade on medical supplies crossing front lines into opposition-held areas amounts to nationalised sanctions on parts of the country.

Doctors have fled the country in huge numbers. Among those who remain are small numbers of medical specialists, doctors-in-training and surgeons with little or no experience operating on war-related injuries. Dentists are performing minor surgeries, pharmacists are treating patients and young people are volunteering to work as nurses.

Today, Syrians are dying not only from bullets, bombs and missiles, but also from easily treatable and preventable chronic diseases such as diabetes and hypertension. Infectious diseases once under control in Syria, including measles and cutaneous leishmaniasis, are breaking out in parts of the country. For women facing pregnancy complications, it’s practically impossible to get emergency obstetric care. The largely collapsed health system in opposition-controlled areas has only been exacerbated by an inadequate humanitarian aid response to fill the gap.

Since the beginning of the conflict, the Syrian authorities have refused to authorize MSF to work inside the country. Because of the immense humanitarian needs, MSF has been forced to engage in cross-border humanitarian aid operations from neighbouring countries into largely opposition-controlled areas.   

MSF’s six hospitals and two clinics in Syria are conducting an average of 10,000 consultations and 430 surgical acts per month, demonstrating the high needs in the limited areas where MSF is able to operate. Where MSF cannot work directly, the organisation has also been supporting 28 hospitals and 56 health clinics throughout Syria, which all report dire shortages of essential medical supplies because of the extreme difficulty of passing medical material through checkpoints and roadblocks.

The Russian and Iranian governments must utilize their strong ties with the Syrian authorities to secure access for aid agencies to operate within areas controlled by the Syrian government and to cross front lines into opposition-controlled areas of the country.  The Damascus authorities must also ease all administrative requirements slowing the distribution of assistance in the country, such as the closure of supply routes, restrictions on the movement of humanitarian aid workers, and other bureaucratic obstacles. Furthermore, the Syrian government must respect the impartiality and neutrality of medical structures and cease all targeting of health facilities, staff, and patients as well as facilitate the movement of medical supplies and staff across front lines and borders.

Key states supporting opposition groups, including the U.S., Turkey, Saudi Arabia, and Qatar, must ensure that these groups facilitate and respect the provision of humanitarian assistance across front lines. These countries must ensure that the opposition groups they support, either directly or indirectly, also commit to cease establishing military bases in proximity to medical facilities, and to stop harassing, threatening, or targeting health workers or patients.   

The responsibility to facilitate and respect the provision of humanitarian assistance in Syria also falls on the shoulders of all armed groups, militias and States that have any influence or involvement in the conflict. Neighbouring countries must keep their borders open to allow the free flow of assistance into Syria and for refugees seeking sanctuary outside the country.

All diplomatic efforts must be taken to ensure that UN agencies and humanitarian aid organisations are able to provide emergency assistance to the people of Syria, whether from Damascus or neighbouring countries.

The unprecedented crisis in Syria demands an unparallelled and concerted diplomatic effort to facilitate humanitarian assistance. Thousands of Syrians are being killed or displaced every month. An agreement to facilitate humanitarian assistance must be central to any attempt to respond to the catastrophic onslaught of this war. The lives of millions of Syrians are at stake.


Dr. Unni Karunakara
International President     
Médecins Sans Frontières

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