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 (New York) – Insufficient levels of humanitarian assistance are reaching opposition-controlled areas in northern Syria, despite their proximity to the Turkish border and dire medical, food, and other humanitarian needs. Human Rights Watch visited Raqqa governorate in April 2013, and Aleppo, Idlib, and Latakia governorates between December 2012 and April 2013.

UN agencies should do more to facilitate and support the expansion of cross-border operations by nongovernmental groups and should actively consider conducting cross-border operations themselves, Human Rights Watch said. The UN Security Council should also send a clear message that cross-border operations are needed to relieve civilian suffering, and should press Syria to allow cross-border operations. Both the Syrian government and armed opposition groups need to meet their legal obligations immediately to allow and facilitate rapid and unimpeded passage of humanitarian relief for all civilians in need.

“There are massive needs for aid across Syria but the towns near the Turkish border are getting next to nothing, raising alarm bells,” said Nadim Houry, deputy Middle East director at Human Rights Watch. “More needs to be done to reach these communities in the north, with or without government permission.”

On June 7, the UN Office for the Coordination for Humanitarian Affairs (OCHA) released its second six-month Syria Humanitarian Assistance Response Plan (SHARP). Carrying out the plan is crucial to meeting urgent humanitarian needs in Syria, but the international response should also address the thousands of people in desperate need in opposition-held areas. The SHARP plan does not include cross-border assistance, because the Syrian government has not given approval for the United Nations or humanitarian organizations to deliver aid to opposition-held areas through neighboring countries.

Donor countries should scale up bilateral assistance to nongovernmental organizations (NGOs) already providing assistance across the border into Syria from Turkey without waiting for Syria’s go-ahead, Human Rights Watch said.

In April, medical professionals and local aid providers in Raqqa city and Tal Abyad told Human Rights Watch that they lacked medical supplies and generators to ensure constant electrical supply to hospitals and adequate food assistance. Since the government has stopped paying salaries, hospitals are also lacking doctors, nurses, and technical staff essential to maintain medical equipment. For example, in the National Hospital in Raqqa, 15 of 28 dialysis machines were out of service when Human Rights Watch visited. Only 25 of the 112 doctors who once worked in the hospital remained. In one day in April, hospital staff told Human Rights Watch, four infants died when the generator providing oxygen to their incubators failed.

Medical and humanitarian assistance providers in Raqqa governorate told Human Rights Watch that their ability to deliver services, which had relied primarily on local resources, was waning and that they might have to discontinue even the inadequate level of assistance they were able to provide at that point because of lack of outside assistance.

Syria has permitted some “cross-line” aid deliveries that originate in Damascus and then are taken to opposition-held areas, but it has not approved sending “cross-border” humanitarian assistance to opposition areas directly from neighboring countries. The government has also imposed heavy bureaucratic hurdles on these cross-line efforts. Aid agencies have said that bureaucratic hurdles and difficulties in moving assistance due to security conditions across the country have meant that only limited aid is getting through Damascus to opposition areas.

On April 22, John Ging, the OCHA director of operations, criticized the Syrian government for requiring UN agencies to enter opposition-controlled areas by crossing dangerous front lines. Speaking to journalists, he said, “There is no logical reason why you can cross a conflict line but not a border… [b]ut there is a consequence: people are dying.”

Some NGOs are delivering some aid directly from Turkey to northern Syria, the NGOs and residents say. But these efforts have remained limited and have not included UN agencies. UN involvement in the cross-border deliveries would help ensure a more effective and coordinated aid effort.

A May 8 UN General Assembly resolution criticized the “failure to ensure the safe and timely provision of humanitarian assistance to all areas affected by the fighting,” and called on the Syrian government to authorize cross-border humanitarian operations. The General Assembly also called on all parties to “grant immediate, safe, full, and unimpeded access of humanitarian personnel to all populations in need of assistance in all parts of the Syrian Arab Republic, in particular to medical facilities, and calls upon those parties to cooperate fully with the United Nations and relevant humanitarian organizations to facilitate the provision of humanitarian assistance through the most effective routes.”

The UN Security Council has failed to pass any resolution calling on Syria to allow cross-border assistance mostly because of Russian opposition, but did issue a non-binding statement, on April 18, that “underlined the need to facilitate the provision of humanitarian assistance through the most effective ways, including where appropriate across borders in accordance with guiding principles of humanitarian assistance.”

Under international humanitarian law, civilian humanitarian relief personnel must be granted freedom of movement by all parties to the conflict, and be protected from attack, harassment, intimidation, and arbitrary detention. The parties to the conflict must allow and facilitate rapid and unimpeded passage of humanitarian relief for civilians in need.

The multiplicity of armed groups and the absence of security guarantees also undermine delivery of aid to opposition-held areas. In April, the World Food Program reported that since it began operations in December 2011, more than 20 warehouses, food trucks, and cars had come under attack, though it was not clear in all cases who the attackers were. In one attack, three food trucks bound for Hasaka governorate were held up by an armed group in Deir el-Zour governorate and the food was stolen.

Armed opposition groups, encouraged by the Syrian opposition coalition, should grant safe passage to relief convoys and personnel into the territories within their control. The Syrian opposition coalition, with the support of donors and international organizations, should also expand the capacity of its assistance coordination unit so that it can do more to coordinate and facilitate the delivery of assistance to people in need in opposition-held areas.

“The opposition leadership in Raqqa governorate near the northern border is struggling to provide municipal, health, and humanitarian services to the local population,” Houry said. “Concerned countries should be helping to ensure that basic health, food, and other needs are met immediately and will continue to be met.”

Problems with Cross-Line Aid
The World Food Programme (WFP) has delivered food assistance to Raqqa governorate and the World Health Organization (WHO) has provided medicine and supplies through local groups to residents in Raqqa governorate, news media have reported. However, on May 10, the WFP announced that they were experiencing significant difficulties in dispatching food from their Damascus warehouse because they “are facing enormous challenges to move around the country.”

On April 18, Valerie Amos, under-secretary-general for humanitarian affairs and emergency relief coordinator, described to the Security Council the difficulties UN agencies had encountered conducting cross-line operations:

In February and March this year, 276,000 people in the most severe need have been effectively cut off from assistance as the government has closed down Syrian Arab Red Crescent cross-line operations. We have similar restrictions in Rif Damascus, Aleppo, Dara’a and elsewhere. These have all been the target of UN-led cross-line missions, but due to access restrictions the scale of aid delivered falls far short of the needs...We need to get aid into these hard-to-reach areas. And it is difficult to do cross-line because of bureaucratic constraints. The [UN Security] Council needs to consider alternative forms of aid delivery, including cross-border operations because too many lives are being lost.

Other UN officials have also publicly recognized the limitation of focusing solely on cross-line delivery. On January 31, OCHA said publicly that it was unable “to reach the vast majority who are in need in the opposition-held areas,” and called urgently for agreement to allow cross-border transfers, noting that “there is no time to lose.”

Lack of Medical Assistance
From April 22 to April 27, Human Rights Watch researchers visited the public hospitals in both Tel Abyad and Raqqa city, and local charity organizations, working to provide food items and basic assistance to families in need in both towns.

Tel Abyad, a town on the Turkey-Syria border that residents told Human Rights Watch is now home to approximately 200,000 displaced Syrians in addition to the local population, is served by one hospital, the Tel Abyad National Hospital. A doctor there told Human Rights Watch that children made up the greater part of the patient population and that at times, two or three were sharing a bed because of overcrowding.

The doctor also said that the hospital lacked medicines for the children for leishmania – a vector-borne disease that causes welts on the skin – as well as for cholera, typhoid, malaria, and other water-borne diseases. The relief coordinator at the Tel Abyad Local Civilian Council, told Human Rights Watch that the hospital also urgently needed dialysis and X-ray machines.

On June 4, WHO warned about the increase in contagious diseases as Syria’s beleaguered health system continues to suffer, and temperatures increase during the summer months: “All the risk factors that enhance the transmission of communicable diseases in emergencies are present in the current crisis in Syria and its neighbouring countries…We are anticipating a number of public health risks from water-borne diseases, specifically hepatitis, typhoid, cholera, and dysentery. Given the scale of population movement both inside Syria and across borders, together with deteriorating environmental health conditions, outbreaks are inevitable.”

In Raqqa, the capital of the governorate, approximately 90 kilometers from the Turkish border, medical staff at the National Hospital told Human Rights Watch on April 25 and 26 that they had critical shortages of basic medications, such as insulin, needed to treat chronic diseases, and that they didn’t have the money they needed to retain hospital staff and repair medical equipment.

Dr. Abdul Nassir el Darwish Ibn Abd al-Hamid, an emergency room doctor, told Human Rights Watch that while some medical assistance has been provided from the outside, it has been very limited and has only met a fraction of the local needs. As an example, he described the situation in the hospital’s Dialysis Department:

We received about 80-100 patients every day at the kidney department alone… [and] two days ago there were no catheters for dialysis sessions… [B]ased on what our doctor colleagues in the kidney department told us, every session needs half a liter of saline… [We do] 2,400-2,800 sessions a month so we need near to 1,300 bags of salt serum a month… the [assistance] deliveries [we receive] are small, we got one small pick-up with supplies from the Turkish people, one of the guys told me that the Syrian/Kuwait Red Crescent provided bags of serum… [To take another example] I asked the blood bank what we need a day, they said one hundred bags of blood. Every day we need it. The assistance that is coming, [though] would be just 100 bags: This is what we need every day.

In addition to inadequate medication and medical supplies, Dr. Abdul Nassir said the hospital did not have adequate funds to repair machines critical for treatment. Fifteen of the hospital’s 28 dialysis machines were out of service when Human Rights Watch visited. He said the CT-scanner had not been working for five months.

The hospital director told Human Rights Watch that, excluding salaries for staff, the hospital needed approximately 20 million Syrian pounds (about US$45,000) to keep the hospital running for a month. He said the hospital was receiving nowhere near that amount, and that only 25 doctors out of the 112 who had worked there were still there. He said that from his perspective, the larger problem was with retaining nurses because their salaries had not been paid since the opposition took control of the area.

Dr. Abdul Nassir described to Human Rights Watch the toll on the remaining staff and the quality of care for patients. He said that he had been sleeping in the hospital morgue for the past 70 days because no one else was available to provide care to the patients. He added that for the most part, he was relying on assistance from student doctors and nurses.

Dr. Abdul Nassir also told Human Rights Watch that power outages have had a dire impact on patients. The hospital has two generators, but both are operating unreliably, he said.

In one case, days before Human Rights Watch researchers visited the hospital, the generator powering oxygen tanks in the hospital failed, resulting in the death, on April 21, of four infants in the early child care ward who relied on the oxygen in incubators to keep them alive.

Lack of Food Assistance
Residents and assistance providers in Raqqa and Tel Abyad also told Human Rights Watch that inadequate levels of food assistance were coming into the area. A resident who was donating his time to distribute food to residents in need in the city of Raqqa told Human Rights Watch, on April 27, that his operation, which fed approximately 10,000 people a day, relied entirely on local community assistance, but that this was not enough and that his operation needed support from the outside.

Human Rights Watch also spoke to a charity coordinator in Tel Abyad and to the relief coordinator of the local civilian council. He said his operation had a shortage of clean water and that some limited food assistance was coming in, but not enough to meet growing needs, including for basics such as flour for bread. The relief coordinator told Human Rights Watch that his unit had received some assistance from the Syrian opposition’s coalition assistance coordination unit including flour, baby milk, and mattresses.

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