The Atlantic quotes TSI’s Executive Director Valerie Szybala about Madaya

The Virtual Surgeons of Syria

By Avi Asher-Schapiro                        8/24/2016

A team of doctors across the world is helping the only two medical professionals left in one besieged town in Syria—via cell phone.

Earlier this year, a Syrian American orthopedic surgeon was shopping with his two toddlers at a Walmart in Grand Rapids, Michigan, when he heard the familiar ping of a notification from WhatsApp, the encrypted messaging service: A teenager had been shot in the leg and the bullet had passed straight through his tibia. The fractured bone punctured his skin like a spear. Although it was the surgeon’s day off, he took the call—as an expert in complex bone operations, this was his specialty.

But this was no ordinary case. His patient was over 6,000 miles away, awaiting care in a makeshift medical clinic in Madaya, a town in Syria some 28 miles from Damascus. The clinic is only a 45-minute drive from Damascus Hospital, but it might as well be on the other side of the world. Madaya, a rebel-held town controlled by the Islamist group Ahrar al-Sham, has been held under siege by Hezbollah, which is fighting on behalf of the Syrian government, since last July. Hezbollah won’t let anything in or out of the town; it was a Hezbollah fighter, locals say, who shot the teenager in the leg.
At the Madaya clinic that day, two men were on duty: a 25-year-old who had been a first-year dental student when the Syrian civil war broke out in 2011, and a veterinarian in his mid-40s. Gangrene had begun to spread down the patient’s leg, and the dental student, in a series of frantic texts, was asking the surgeon in Michigan what to do. As he walked through the parking lot of the Walmart, the surgeon picked up the phone and called the dental student, guiding him through the steps: Immediately load the patient up with antibiotics. Scrub the wound. Clear away as much dead tissues as possible without agitating the patient. Splint the leg.
The Death of Hope in Syria

“Any other call I would have ignored,” the surgeon admitted to me when we spoke in early August. But he knew that the dental student had nowhere else to turn. He is the only orthopedic surgeon in the “Madaya Medical Consultants,” a group composed of over two dozen, mostly Syrian American doctors, whose specialties include pediatrics, obstetrics, and pulmonology. They meet, digitally, in a WhatsApp chat room that supports the Madaya clinic around the clock. Most of the doctors in the group quoted in this story asked not to be identified, for fear of endangering their families in Syria. Rajaai Bourhan, a resident of Madaya, introduced me to the Madaya clinicians, whose identities I’ve also left anonymous for similar reasons.

Throughout Syria, more than 500,000 people are now under siege. The vast majority are penned in by pro-government fighters, their survival hinging on the medical know-how of the doctors, nurses, or medical students who happen to be trapped with them. In clinics like the one in Madaya, medical expertise is increasingly hard to come by, and remote medicine is often the only way patients with complex ailments can receive a semblance of care.

In Madaya, a year-long blockade enforced by a series of Hezbollah checkpoints, backed up by deadly minefields, has separated its 40,000 civilians from the rest of the country. The town hasn’t received a humanitarian-aid convoy since May, and only the most gravely injured or sick are allowed safe passage out. These evacuations require complex negotiations with rebels in other parts of Syria, in a high-stakes human trade.
This places a tremendous burden on the Madaya clinicians, the town’s two remaining full-time medical workers. Neither man has ever set foot in a medical school. The town’s most-skilled medical practitioner, a nurse with a background in anesthesiology, managed to escape last spring after receiving death threats.

But even the stifling siege can’t keep out wi-fi, which permeates the town thanks to a cluster of nearby cell-phone towers operated by Syriatel, the Syrian cellphone giant owned by Rami Makhlouf, President Bashar al-Assad’s cousin. In February 2016, a pulmonologist in Indiana who grew up outside Madaya realized he could use that wi-fi to smuggle medical advice past the blockade. During the winter of 2016, Madaya’s food stores emptied out. Dozens starved to death, and the health clinic swelled with malnourished patients. As the body count rose, the pulmonologist—a board member of the Syrian American Medical Society (SAMs), a humanitarian organization staffed by Syrian American doctors—grew increasingly desperate to boost the capacity of the town’s small clinic.

“It was the only way I could think of to help,” the pulmonologist told me recently. SAMs runs similar telemedicine programs in other parts of Syria, but Madaya is one of the only besieged areas without any trained doctors. After the anesthesiologist nurse fled, he knew the clinic would need more help than he alone could provide.

In February, the pulmonologist wrote an SOS on his Facebook page (he’s shared the posting, but asked me not to make it public since it includes names of doctors who want to remain anonymous) asking Arabic-speaking doctors to join a WhatsApp chat room that would become Madaya Medical Consultants. Within 24 hours of posting the message, over two dozen doctors joined, he recalled. Not wanting to overcrowd the group, he eventually started turning people down.

“God willing, I am able to help as many people as possible.” The dental student remembered the first time the doctors in the WhatsApp group helped him make a diagnosis. The day after the pulmonologist introduced him to the group, a child, whose body was body swollen and misshapen, was brought into the clinic. One of the group’s pediatricians helped identify the patient’s ailment as kwashiorkor, a disease brought on by extreme protein deficiency. First identified during a famine in West Africa in 1935, its name comes from a Ghanaian term for a child whose mother does not have enough breast milk to feed it. To treat the condition, a pediatrician in Chicago helped devise a formula using vegetable proteins that accustoms children to a high-protein diet. “We were so thankful that these doctors from so far away would volunteer their time to help us,” the dental student said.

The five-year civil war has plunged the Madaya clinicians into the deep end, forcing them to perform medical procedures that push them far beyond their training. They have treated countless gunshot victims, performed seven amputations, over a dozen C-sections, and diagnosed everything from meningitis to cancer, they told me during multiple conversations over WhatsApp and Facebook. “I’ve learned as I go,” the dental student said when we chatted over Facebook in August. “God willing, I am able to help as many people as possible.”
But there are limits to what they can do. Every day, one member of the group, a Virginia-based internist, obsessively checks the WhatsApp group for new messages: at 4 a.m. when she wakes up to breastfeed her newborn daughter, or on her lunch break at her clinic. In recent weeks, she has been trying to help the Madaya clinicians diagnose a woman who suddenly lost her vision, without warning, and is experiencing hallucinations. If a patient walked into her clinic with those symptoms, the internist said, she would immediately order an MRI. But since there’s no MRI machine in Madaya, she and three other doctors have been working to diagnose the woman “empirically,” trying out different medications the clinic happens to have and seeing if they work.

In July, as the internist recovered from the birth of her second child, she helped the Madaya clinicians perform a C-section on a woman pregnant with twins. The veterinarian, fortunately, was comfortable making the incision. But he was unprepared for all the blood the mother would lose after giving birth to two babies. So the internist explained that the woman needed a transfusion. She advised the dental student to transfer two units of blood every 30 minutes—the gap between transfusions was critical, she explained, to allow time to observe whether the mother was having an allergic reaction to the blood.

No amount of hands-on experience—even crash courses in surgery and complex diagnostics—can substitute for formal training.
The whole exchange took place in a series of rapid-fire text messages. Though the Madaya clinicians sometimes send photos or videos of their procedures, the town’s patchy cell-phone-enabled internet service can’t reliably stream videos, and only sometimes supports phone calls. In the end, the C-section was a success; the newborns and mother are healthy and back at home. Still, no amount of hands on experience—even crash courses in surgery and complex diagnostics—can substitute for formal training. “Sometimes, talking to those two is like speaking with a first-year medical student,” the internist said. “You never know what they will know or what will be new to them.”
Doctor Silvia Dallatomasina, the medical-operations manager for Doctors Without Borders’s Syria office, explained that almost everywhere across the country “the medical staff is young or inexperienced, out of their comfort zone.” That dynamic is supercharged in Madaya. “There’s no second clinic to fall back on. You can’t bring in a doctor from a neighboring community,” explained Valerie Szybala, the executive director of the Syrian Institute, a nonprofit that helps run Siege Watch, a project monitoring Syria’s besieged communities. “For patients, there is nowhere to go. It’s that clinic, or nothing.”

At times, the group does indeed resemble a classroom. For hours every day in the chat group, doctors and the Madaya clinicians discuss the merits of different antibiotics, or analyze the urine of a patient, or try to devise a workaround for a surgery. The orthopedic surgeon in Michigan recently taught the dental student how to perform minor hand surgery without general anesthetic by suppressing a nerve in the hand to temporarily numb a wounded finger. “We became more professional, more precise,” the dental student said. “In some ways, its been an academic experience, learning things I had no way of knowing before.”

“We thank God for the group,” the veterinarian told me at the end of a full-day shift at the clinic, via a WhatsApp audio message. “Without them, we would have more questions than answers.”

For many of the doctors in the WhatsApp group, the digital thread tethering them to Madaya has become an obsession. The pulmonologist described constantly looking at his phone, even while driving in traffic, to make sure the group is answering all the questions that come up. “I can’t let it go,” he said. “My soul is attached there.” The orthopedic surgeon said he checks the chat room “multiple times every day.” Before the WhatsApp group, he had to switch off the television whenever it showed images of the Syrian civil war, overwhelmed by a feeling of helplessness. “I just shut my brain up. I didn’t want people even talking to me about it,” he said.
For the past five years, he has been in touch with his family in Aleppo, the northern province that’s become the center of the Syrian conflict in recent months. When his cousins talk about the horrors of life in a war zone, all he can say is “I’m sorry, I’m sorry,” leaving him feeling “like a jackass,” he said. Though he has no personal connection to Madaya, the WhatsApp group has given him a feeling of concrete solidarity with those suffering in Syria.

Born and raised in Damascus, the internist hasn’t been able to return to her native Syria or see her parents in five years. The WhatsApp group, she said, offers her a “portal” back into her homeland, a rare opportunity to alleviate suffering. She still has fond childhood memories of Madaya: She and her sister used to drive there from Damascus to buy rare fruits smuggled into Syria from across the Lebanese border.

Remote medicine, of course, is not enough to keep Madaya healthy. Many of the conversations in the WhatsApp group fizzle out as the doctors realize the clinic doesn’t have the right medicine or equipment—or that the Madaya clinicians can’t perform the needed procedures, like brain surgery or a lumpectomy. At that point, the doctors will promise to pray for the patient, and the chat room goes silent. When asked if these dead ends discourage him, the pulmonologist paraphrased a verse from the Koran: “If we save one life, it is as if we are saving the whole of humanity.”


Siege Watch cited in Syria Deeply article on the siege economy

The Siege Sector: Why Starving Civilians Is Big Business

WRITTEN BY Annia Ciezadlo  PUBLISHED ON Aug. 11, 2016  READ TIME Approx. 5 minutes

As 2 million people are at risk of coming under siege in Aleppo, researcher Will Todman speaks to Syria Deeply about the war economy that has taken hold in besieged areas across the country.

BEIRUT, LEBANON – Starving civilians into submission is a war crime. Yet siege warfare has become a widespread tactic in the Syrian conflict, especially with government and pro-government forces, for one simple reason: It works.

But while sieges are a brutally cost-effective way to win back territory with minimal cost, there’s another, even uglier reason they’ve become so popular in the Syrian conflict. As some of the country’s longstanding sieges enter their fifth year, starvation itself has evolved from a military tactic into a profitable underground economy.

Besieged civilians are a captive and extremely lucrative market. Today, at least 590,200 people are officially under siege in Syria, according to the United Nations; the independent watchdog group Siege Watch estimates that over 1 million people are being deliberately starved, most of them by the government. The traders and business people who control the flow of black-market goods into besieged areas reap enormous profits. “It’s not only money that people are gaining from this, but also goods,” says Will Todman, who wrote a recent report for the Middle East Institute on siege profiteering. “And even winning loyalty comes into it.”

Todman spoke to Syria Deeply about the war economy that has grown up around sieges inside Syria, how traders and profiteers manipulate prices, and some of the dilemmas for humanitarian groups trying to bring aid into besieged areas.

Syria Deeply: Your report was a portrait of what I would call the “siege sector.” Did you get a sense of the overall size of this sector?

Will Todman: It’s difficult, because these things fluctuate so much. The prices are constantly going up and down. The traders will lower their prices to meet whatever they think demand is, or whatever they think people can pay.

One indication is the Wafideen crossing, out of Eastern Ghouta, near Douma. It’s nicknamed the Million Checkpoint [Hajez al-Milyon]. The soldiers on the checkpoint are taking a million Syrian pounds [about $4,600] an hour from bribes. That’s just a fraction of the whole thing.

Syria Deeply: Everyone I’ve talked to in besieged areas has described a similar pattern of selectively banning certain goods: One week you can’t bring in bread, the next you can’t bring in chickpeas. At first everyone thought this was a form of psychological warfare. After reading your report, I’m beginning to wonder if those running the checkpoints are banning certain goods in order to manipulate prices.

Todman: I’m sure psychological warfare plays a role in it. But the overwhelming thing, which I hadn’t really appreciated when I started looking at this, was the economic side.

I think sieges did start as a military tactic, and they’re pretty effective. From a counterinsurgency military perspective, early on they achieved their aim: Look at the very first siege, of Daraa, which went on for about 10 days and made things settle down again. Elsewhere, on a bigger scale, ultimately you could say that they worked.

But now it’s become about making money. Traders get agreements from very high up, often from connections in the regime, to be allowed to import a certain good. Because there’s so few goods getting in in the first place, it’s really difficult to try and nurture alternative economic networks that could form some kind of competition. They’re free to exploit as much as they want. Eastern Ghouta is the prime example of this economic exploitation.

So I wouldn’t be surprised if this tactic of allowing a certain product in one day, and then not, might be to try and make the most profits. To let the demand increase, and then suddenly allow them in, and take lots of money when everyone’s desperate for something – for cooking oil, fuel or whatever it might be.

I tried to trace the evolution of corruption, really both in the Syrian army and also with pro-regime militias. I think that might help explain how the profiteering aspect of this came about. There are a few examples that show just how important that is.

Hezbollah took over the checkpoints at Madaya in late 2015. That’s when those horrific, horrific images of emaciated children and civilians came out. It was so stark that this was after Hezbollah had taken over, because I think they’re much less corrupt than either the Syrian forces or pro-regime militias. So, soon after a change in the actor enforcing the siege, you can suddenly see that impact. That was an indication to me just how much corruption was going on.

Syria Deeply: So the lack of corruption actually caused people to starve more? There’s an interesting point there about the role of smuggling and bribery and profiteering – that perhaps they also help people to survive.

Todman: I spoke to someone with good contacts in the regime who said that soldiers are sent to sieges as a reward. They’ll get sent to wherever the front lines are at the moment; and then, almost like a vacation, they’ll get posted to a checkpoint by a siege, and effectively given the green light to exploit as much as they can. Because they don’t know how long they’re going to be deployed there, or when they’ll next be paid their salary.

Syria Deeply: Did you hear of any examples of that happening with anti-government or pro-opposition militias as well?

Todman: I didn’t speak to anyone living inside an opposition group siege, but I heard anecdotally that these things are happening there as well. I got the impression that it’s almost as though they’d learned from what the regime was doing and were trying to mimic it, as a means of making money, and also as a means of revenge.

I’m not trying to ignore the sieges that aren’t imposed by the regime. But they’re so overwhelmingly imposed by regime or pro-regime forces that I do think it’s appropriate to focus on that. Often the armed groups who are being besieged find ways of benefiting from this as well. But it’s always the civilians who end up right on the bottom.

Syria Deeply: What about sieges by ISIS or Nusra?

Todman: I heard from people in Deir Ezzor that it’s much more difficult to get goods in through ISIS checkpoints. There’s not the same levels of smuggling at all. There doesn’t have to be, because the regime can still fly all that stuff in. This is why I would define Deir Ezzor as being besieged by the regime and ISIS at the same time. Because the ways in which goods are distributed once they’ve been flown in through the military airport, I would say, are very similar to sieges elsewhere. It’s not physically going through a checkpoint, but the quantities are still designed in a way to increase the amount they can make civilians there pay.

Syria Deeply: Sieges are by definition hard to break. But do you see any viable ways to alleviate the human suffering of people inside besieged areas?

Todman: U.N. convoys are incredibly problematic. Yes, we’re seeing a few more now, but it’s still meeting a fraction of the need, and not sustainable at all. The things that are being sent in are not really the things that people need to be able to restart their lives.

But if you’re looking purely at the war economy, I do think that convoys are probably one of the best ways of breaking the hold that some of these actors have over the whole system. It’s far from perfect, and I wouldn’t say that’s what we’ve got to do, but I think they are one of the ways of helping. Obviously the best thing is to stop the sieges.


“There is a regime offensive across the board,” TSI executive director quoted in Fox News

Assad, Russia go on the offensive in Syria while UN sees ‘very positive’ discussions

The long running civil war in Syria appears to be entering a new and even grimmer stage, with troops loyal to President Bashar Al-Assad intensifying a widespread offensive on the city of Aleppo and elsewhere, including, according to residents, renewed use of chlorine barrel bombs.

Opposition forces were fighting desperately to break a now solidly-established siege of eastern Aleppo, the largest remaining center of resistance to the Russian-backed forces of Bashar Al-Assad, where food, fuel and medical supplies for some 350,000 people are dwindling.

An opposition offensive that began earlier in the week was renewed Friday morning, according to humanitarian workers in the city who were contacted by Fox News, though they could offer no sense of how the battle was going.

Meantime, regime forces were on an offensive of their own, not only in Aleppo but at besieged areas throughout the devastated country, with strong Russian air support.

“There is a regime offensive across the board,” said Valerie Szybala, executive director of the Syria Institute, a non-partisan think tank studying the conflict. “It undermines the possibility of getting back to the [negotiating] table.”

It has also created a de facto blockade against humanitarian relief efforts that U.N. officials say they are ready to deliver, if only given a chance.

“We are ready, able and willing to go, if there are pauses in the fighting,” declared Jan Egeland, a Norwegian politician acting as special advisor to the U.N. Special Envoy for Syria, on Thursday.

Except the pauses aren’t happening. “There is fighting in too many places,” Egeland said. As a result, humanitarian relief—he did not say how much—had reached only 40 per cent of some 1.2 million people the U.N. hoped to reach in July.

Earlier U.N. –sponsored deliveries to besieged areas were sparse, sporadic and often limited by the Assad regime to supplies that the government forces decided were acceptable, which often excluded vital medical supplies, for example.

A key factor in the battle is incessant Russian air strikes, which have, according to military observers, continued at a high pitch, even as Russian officials remain involved in international ceasefire talks and claim to be holding open “humanitarian corridors” to allow Aleppo residents to escape from bombing and artillery barrages.

“We have seen Russian airstrikes go up to pre-cessation-of-hostilities levels, and not only in Aleppo City,” said Genevieve Casagrande, an analyst at the Washington-based Institute for the Study of War, referring to a watery cease-fire agreement negotiated last February, which began to erode almost immediately.

“They are targeting neighborhoods where everyone knows there are only civilians,” said Hamza Al Khateeb, director of the Al Quds hospital in Aleppo, who spoke with Fox News by telephone. He said opposition forces were able to identify Russian MiG warplanes not only by sight but by air chatter as they they made bombing runs.

The Russian attacks have often been aimed at civilian targets, including hospitals, clinics and other health facilities—including Al Quds, which was attacked seven times in April, according to Al Khateeb. More recently, two improvised barrel bombs—used by Assad regime forces—had landed across the street, no more than 50 ft. from the battered hospital.

Air attacks had also targeted morgues, he said, killing at least two medical workers and injuring five.

Another doctor was reported injured by Dr. Osama Abo El Ezz, General Surgeon and Aleppo Coordinator of the Syrian American Medical Society, who had to break off a phone call with Fox News to attend to a 15-year-old severely injured in the chest and abdomen by bombing. The teenager died.

( All told, 44 health facilities were reportedly hit in June alone, according to the U.N.’s Egeland, who said “we are investigating all of these.”)

Abo El Ezz called the general situation “horrific,” and said medical workers were treating as many as 100 people on some days, with 20 of them requiring work in intensive care units. “I think the Russians will do their best to kill more and more to make the opposition break,” he said.

Abo El Ezz also made the assertion that chlorine bombs had been dropped “on the north side of Aleppo City.”

“We are running out of many things,” said Al Quds director Al Khateeb. “We have medical supplies for about one month,” echoed Abo El Ezz. Electricity at their hospitals is provided by generators, which run for only part of the day, and fuel supplies for them are running low.

Other items in short supply included purified water and just about any kind of fresh food, as well as milk powder for children.

As for the so-called “humanitarian corridors,” Aleppo residents considered them a fraud. They remain under Russian control and do not offer access to any of the badly needed humanitarian supplies.

Indeed, admitted Egeland, “we do not have classical humanitarian corridors at all, in Aleppo, but we’re working with everybody, including Russia, to get those.”

Nonetheless he added that “the discussions have been very positive, in a sense that everybody now says that we are working towards the same goal of having two-ways humanitarian corridors, of having better protection of civilians, including medical installations.”

Egeland admitted that the number of civilians taking advantage of the escape corridors was “very limited so far.”

That was hardly surprising, according to medical workers, who told Fox News the corridors were targeted by regime snipers and were considered death traps to those who even came close to them.

Al Khateeb reported that a nine-year-old girl who strayed close to one of the corridor areas on Friday was shot in the stomach. She survived. Medical workers reported other recent anecdotal cases of civilians shot down in the corridors who were less lucky.

“You cannot trust anyone who is besieging you,” said Bakri Al Halabi, the head of an eastern Aleppo cultural Center, about claims that civilians could use the corridors safely. “It’s just a lie from the government in front of the United Nations.”


MEE quotes TSI’s Szybala on besieged Aleppo

Fresh fighting in besieged Aleppo, residents ration food, fear what’s to come


Despite ceasefire claims rebel and government strikes kill 42 civilians, as Aleppo residents say they fear a long blockade.

Last update:
Saturday 9 July 2016 14:08 UTC

About 300,000 residents in rebel-held Aleppo are besieged after government forces seized the last main road into the city’s eastern side, as rebel strikes killed at least 38 civilians on Saturday.

The government’s capture of the Castello Road on Thursday, previously the only rebel-held artery into Syria’s largest city, came two days after the Syrian army declared a 72-hour ceasefire for the Eid al-Fitr holiday.

The road’s seizure has effectively cut off residents in the eastern area of the divided city from being able to leave and food and other supplies from entering, raising concerns of a long-term siege.

On Saturday opposition fighters renewed rocket fire on the government-held west of the city, in strikes that killed at least 38 civilians, according to the Syrian Observatory for Human Rights.

The Britain-based monitoring group said 14 children were among the dead, while Syrian state media gave a toll of 43 dead and 300 injured.

Fresh government air strikes on rebel neighbourhoods also killed four civilians on Saturday, the monitor reported.

The fresh airstrikes and rocket attacks came despite a claim from the Syrian army that it was extending the earlier truce for another 72 hours.

There were also reports of government strikes east of Damascus, where Syrian army troops took the town of Midaa, severing a key rebel supply route to the opposition-held Eastern Ghouta region.

In the east of Aleppo on Saturday, residents described shortages of basic goods after government troops advanced within firing range of the key Castello Road supply route.

“For two days the situation was calm, I went to the market and I filled up my motorbike with gasoline. Today, I couldn’t even find a single tomato,” said Bilal Qaterji, a local textile factory employee.

“There’s not a drop of fuel left because the Castello Road has been cut,” the resident of the Bustan al-Qasr neighbourhood told AFP.

In Aleppo, residents in the east of the city said they feared ongoing shortages if the Castello Road remained closed.

“I worry that the Castello Road will be cut for a long time, it will lead to shortages of bread and other necessities,” said Ahmed Kanjou, an unemployed father of four.

The Castello Road wraps around Aleppo’s eastern and northern edges and leads into rebel-controlled territory north of the battered city.

President Bashar al-Assad’s forces have been trying to cut the key route for more than two years and their Thursday advance brought them the closest so far to achieving that goal.

On Saturday, the Syrian army was less than 500 metres (yards) from the key road, and were firing at anyone attempting to use the route.

“Shortly after [the road closure], the people will go hungry,” Fadi al-Halabi, a journalist based in the rebel-held side, told Middle East Eye on Friday. “[A] blockade is death, just slowly.

“The blockade is the hardest thing. I do not know what happens after a week. Now, yes, [I have food]. Tomorrow, I don’t know.”

Halabi said the blockade had an immediate impact on fuel and food prices in the city as supplies ran low and residents tried to stock up.

One kilogram of cucumbers, for example, would have cost five Syrian pounds (SYP) [23 US cents] before the war, he said. It cost 75 SYP earlier this week and jumped to 100 on Friday.

The government has been accused of using siege tactics to pressure rebel forces, and the UN says nearly 600,000 Syrians live in besieged areas, most surrounded by government forces although rebels also use the method.

Laila Kiki with The Syria Campaign, an advocacy group campaigning for the protection of Syrian civilians, said she had spoken with a social worker in eastern Aleppo on Friday morning who was cooking with less food because she was worried about a siege.

“Already from today,” said Kiki, “they started to think, ‘Maybe I should keep some extra things.’”

Over the past three days, Halabi said, there had been continuous aerial bombardments, which he believed to be Russian.

His account is backed up by a US intelligence official, who told Reuters on Thursday that in recent weeks Syrian forces, supported by Russian firepower, had “intensified their efforts to isolate and encircle opposition forces in Aleppo”.

On Friday, the United Nation’s Office for the Coordination of Humanitarian Affairs said it was “extremely concerned at the unfolding situation in Aleppo” and for civilians trapped in eastern part of Aleppo City due to heavy clashes along Castello road, the only road in and out of this part of the city.

Farhan Haq, deputy spokesman for the secretary-general, said: “Heavy fighting over the past few days has continued to put civilians at risk of death and injury while effectively cutting off humanitarian’s access to people in need of assistance.

“This follows intensified fighting by all parties to the conflict in Aleppo city and surrounding areas in recent weeks, including reports of air strikes, shelling and heavy clashes, causing many civilian casualties and injuries. It has also caused damage to schools, hospitals and other civilian infrastructure, and hindered humanitarian aid operations.”

Syrian state-run news agency SANA reported on Thursday that soldiers were carrying out “counter-terrorism operations in Syrian provinces, establishing control over new areas in Aleppo”.

“Army units are continuing their operations and now are hunting down fleeing terrorist groups in the area,” the agency said.

In a video posted to YouTube on Thursday, al-Raed Yasser Abdel Raheem, head of the Free Syrian Army’s Aleppo Operations Room, said his forces would not allow the city to be besieged.

“We will not allow them to blockade this city, we will not allow their planes to scare us,” he said.

“You are the patient ones, the warriors, they are mercenaries who took money to occupy our lands – do not let them.”

‘Planning and stockpiling’

For two years, Syrian forces have been trying to capture the rebel-held road, with the potential siege as a threat.

For this reason, Valerie Szybala, a siege monitor and executive director of The Syria Institute, based in Washington, DC, said, even if the government continues to besiege the city, Aleppans in the east side are unlikely to be on the brink of mass starvation in the next couple of weeks.

“It’s been an off-and-on-again threat so long that maybe some people became complacent,” she said. “But there has definitely been planning and stockpiling.”

As of 5 July, the UN Office for Coordination of Humanitarian Affairs, the agency responsible for monitoring and bringing aid to besieged areas, said there were more than 354,000 people living under siege in Syria, more than half in areas surrounded by the government.

The agency has come under fire for allegedly downplaying the numbers, categorising some Syrians as “hard-to-reach” instead of besieged. Siege Watch puts the figure at more than one million, while NGO Doctors Without Borders has said it is almost two million.

Between 250,000 and 400,000 Syrians are thought to be living in the rebel-held eastern portion of Aleppo.

Eastern Aleppo is the largest urban siege in the country, with conditions that differ from the majority of the sieges, which are in rural areas just outside Damascus, Szybala said.

“Urban areas fare worse generally because the rural areas have more avenues for coping. There is more room to farm and arable land,” she said.

Siege Watch mentioned by Inverse

Siege Warfare Defines the Syrian Conflict and Civilians are Losing

Published June 30, 2016                                               by John Knefel                                                 Inverse

Over one million people spread over 46 cities and villages are feeling the effects of life under siege. They are starving and they are dying of treatable disease because, a new report makes clear, of decisions made by Syrian president Bashar al-Assad. The report, which comes from the monitoring group Siege Watch, The Syria Institute in DC, and the Dutch peace organization Pax claims that 1.5 million Syrians are under serious threat of becoming besieged. It’s a number that is all the more alarming given the current death toll, which is climbing past 400,000. Many of those deaths have come because non-combatants have been unable to escape active fighting or receive aid.

The report points out that this is not a product of unfortunate happenstance. “The convoys that have been approved and implemented have not reached all of the besieged communities and in most cases have failed to bring in sufficient quantities of food aid,” the report states. “The majority of medical aid continues to be removed from convoys.”

No small wonder then that an increasing number of Syrians have attempted to make the dangerous journey to Europe. Those who remain in the country are often at risk of starvation, malnutrition, a lack of access to medicine, an inability to travel short or long distances due to checkpoint or sniper fire, and lack of water access. In one particularly dramatic example, after aid trucks reached Madaya, a rebel-held city in rural Damascus governorate, the UN undersecretary for humanitarian affairs tweeted out that “we found some 400 people that need to be evacuated IMMEDIATELY for medical treatment or face dying.”

The new report from Siege Watch added the eastern portion of Aleppo City, one of the most symbolically important rebel-held areas, to its “watchlist,” which means it is suffering siege-like conditions. As of the reporting, there was one road in and out of the city, which, if overtaken by the regime, could plunge 300,000 residents into potential starvation.

Beginning in February of this year, the opposition and government forces entered into a fragile truce and the beginnings of potential diplomatic resolution to the war. Early cynicism to the efficacy of the effort has unfortunately born out, as the regime and to a lesser extent opposition groups violated the cessation of hostilities, as the truce was known. That cessation has effectively broken down, according to the Syria Ceasefire Monitor project.

Despite the increased diplomatic efforts – which stalled in April – not a single siege was lifted from February to May, when reporting for the current study ended.

The report describes as area as under siege when “it is surrounded by armed actors who restrict the movement of goods and people into and out of the area. A siege is an intentional tactic meant to deprive a populated area of the essentials needed for life.”

Crucially, the Siege Watch report numbers break from official United Nations findings. Official UN figures put the number of Syrians under siege at 592,000 – far below what PAX and The Syria Institute found. This undercounting, the groups say, can result in a skewed impression of just how dire the situation is across vast swaths of the country. “Only when the full scope of the problem is recognised by the international community will the necessary response be undertaken to provide relief to long-besieged Syrians,” said Marjolein Wijninckx, Syria programme manager at PAX, in a statement.

Deliberately putting cities and villages under siege is a violation of multiple UN resolutions, as well as the Geneva Conventions, which makes it a war crime. There is overwhelming evidence that the regime has done just that. “As protests gave way to all-out war, and the country tried to adjust to the sudden disruption of daily life, the government devised a devastating strategy to combat rebel forces: It bombed the increasingly long bakery lines caused by the scarcity of wheat in contested areas of the city,” reports Emma Beals in a fantastic new story at Vice. “These bombings have continued throughout the conflict; in a recent attack, Russian airstrikes reportedly struck a bakery that had provided bread for nearly 45,000 people.”

Other civilian targets, such as schools and hospitals, have been regularly targeted over the course of the war. More than 700 doctors and medical workers have been killed since the war began, according to a recent United Nations investigation. Most of the deaths were determined to be from aerial attacks, which implicates the Syrian and Russia governments, as neither opposition groups nor ISIS have air attack capabilities.

John Knefel is a freelance journalist covering national security and civil liberties. He is the co-host of Radio Dispatch, a daily political podcast.