(New York) – The suffering of civilians in the Syrian town of Madaya shows the need for concerted international action to deliver aid to government-besieged areas. The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) said in December 2015 that close to 400,000 people in Syria are under siege, and that only 1 percent had received food assistance and less than 1 percent had received health assistance between September and November.

United Nations observers talk with local residents during a field visit to the Madaya area, near Damascus May 6, 2012.

© 2012 Reuters

Local activists and residents in Madaya, under siege since July by both government and allied Hezbollah forces, told Human Rights Watch in phone interviews that the government has prevented aid from going in since October. As a result, residents are suffering from an increasingly severe shortage of food and are dying from lack of medical care, residents and activists said. According to Médecins Sans Frontières, otherwise known as Doctors Without Borders, 23 patients in the health center it supports in Madaya have died of starvation since December 1.

“The suffering in Madaya should serve as an urgent reminder that the people in besieged areas of Syria are desperate for food, shelter, and health care,” said Nadim Houry, deputy Middle East director. “Access to besieged communities should be a test of the intentions of the warring parties, who say they will enter into sincere negotiations later this month.”

The suffering in Madaya should serve as an urgent reminder that the people in besieged areas of Syria are desperate for food, shelter, and health care. Access to besieged communities should be a test of the intentions of the warring parties, who say they will enter into sincere negotiations later this month.

Nadim Houry

Deputy Middle East Director

Under international humanitarian law, all parties to an armed conflict are obligated to facilitate rapid and unimpeded humanitarian assistance to all civilians in need and allow civilians to freely leave an area under siege. Starvation as a method of warfare is prohibited.

On January 7, 2016, the UN said it had brokered a deal with the Syrian government to allow aid to finally enter Madaya and two other towns, Fu`a and Kefraya, in Idlib province, which are under siege by armed groups opposed to the government. The International Committee of the Red Cross said that the aid would be delivered jointly by the UN and the Syrian Red Crescent, hopefully on January 11.

Human Rights Watch spoke to several residents and activists in Madaya. They said the town did not have adequate electricity or water, and that the Syrian government was not allowing people to enter or exit the town, including aid workers trying to reach civilians in need. Doctors said that their patients’ bodies were emaciated and weak due to hunger and that people were resorting to picking through garbage to eat. The UN humanitarian affairs agency said the Madaya area has not had aid or commercial access since October 18, 2015, and that residents were in dire need of food and health supplies.

“Some of us had to kill cats and dogs in order to eat,” Abu Ammar, a Madaya resident, told Human Rights Watch. “Others only have salt and water to keep them going.” The residents are not identified by their full names for their protection.

Um Ayman, a mother of four, said she had lost 30 kilos in just a few months from hunger and was reduced to feeding her children boiled tree leaves with some fat and salt.

“My children wake up in the middle of the night crying because they are hungry,” she said. “But what can I do. I don’t have any food to give them.”

A doctor in Madaya said that medicine and health supplies were in short supply, with health facilities’ emergency rooms flooded with people suffering from fainting spells due to a lack of food and water.

“I can now only give medicine to anyone who is absolutely going to die because otherwise I’ll completely run out,” said Khaled Mohamed, a doctor who works in a field hospital in Madaya. “Sixty percent of the cases I see in the hospital are children suffering from severe malnutrition.”

Doctors sent Human Rights Watch photographs from the field hospital’s emergency room showing emaciated children and adults whom they said were suffering from malnutrition. While the photos could not be independently verified, they are consistent with the conditions residents described.

In February 2014, the UN Security Council passed resolution 2139 to guarantee the delivery of aid, calling all sides in the Syrian war to facilitate humanitarian access to all parts of Syria. In light of the Syrian government’s failure to comply, the council passed resolution 2165 on July 14, 2014, authorizing UN agencies and their implementing partners to deliver aid across four borders not controlled by Syria’s government. Aid organizations have reported that the Syrian government has removed some bureaucratic obstacles but continues to bar access to areas besieged by the government.

On December 18, the Security Council adopted resolution 2254 endorsing a road map for a peace process in Syria and calling on all parties in Syria to “allow immediate, humanitarian assistance to reach all people in need, in particular in all besieged and hard-to-reach areas.”

According to the UN humanitarian affairs agency, 4.5 million people in Syria live in hard-to-reach areas, including 400,000 people in 15 besieged locations. These areas suffer from bombing, and inadequate aid, nutrition, water, and medical care. The agency said, in December, that Madaya had last received a joint convoy of aid on October 18, and that there were medical evacuations in December, but that the Syrian government has denied access to the area since then.

According to the UN, Syrian government forces have 200,000 people under siege in Eastern Ghouta, Daraya, Zabadani, and Madaya; Islamic State (also known as ISIS) forces have 200,000 people under siege in Deir ez-Zour; and armed groups, including the al-Qaeda affiliate al-Nusra Front, have 12,500 more people under siege in Fu`a and Kefraya, in Idlib.

Madaya, 40 kilometers west of Damascus, the capital, has just over 40,000 people, of whom 17,000 have been displaced from neighboring towns and villages, the UN agency says. The area has been under the control of anti-government forces for almost two years and under siege by government forces since July 2015.

According to the International Committee of the Red Cross, which was allowed to deliver aid to Madaya in October, people were suffering from a shortage of electricity, water, basic medicines, and infant formula.

Countries that are members of the International Syria Support Group, which has been meeting to push for a Syrian peace process, should use their influence with the warring parties to ensure that aid is allowed into all besieged areas, Human Rights Watch said.

“While the Syrian government finally conceded that it would allow aid into Madaya, it shouldn’t take starving children and media outrage for aid to be delivered,” Houry said. “Countries backing a political solution in Syria need to push the warring parties to allow aid to all those suffering in Syria.”