Syrian Army soldiers monitor residents who said they have received permission from the Syrian government to leave the besieged town as they wait with their belongings after an aid convoy entered Madaya, Syria, January 14, 2016.
Syrian Army soldiers monitor residents who said they have received permission from the Syrian government to leave the besieged town as they wait with their belongings after an aid convoy entered Madaya, Syria, January 14, 2016.
Omar Sanadiki / Reuters

Besieging civilians—cutting them off from food, supplies, and fuel—is a war crime. It is also a strategy that several parties to the conflict in Syria use, chief among them the Syrian government. Estimates of the number of Syrians currently living under siege vary widely, according to who is doing the reporting. For example, last December, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) in Damascus communicated back to the UN secretary-general’s office that 393,700 civilians were besieged. For the same period, Siege Watch estimated that the real figure was more than one million.

The disparity seems related to OCHA’s desire to stay in Damascus, which requires that it stay in the good graces of the regime of Syrian President Bashar al-Assad. That pandering to the Assad regime can also be seen in changes OCHA made to its 2016 Humanitarian Response Plan after a review by the Syrian government. Presumably based on Syrian objections, Yacoub El Hillo, OCHA’s resident coordinator, and Kevin Kennedy, OCHA’s regional coordinator, deleted every single reference to “siege” or “besieged” populations. From its base at the five-star Four Seasons Hotel in Damascus, OCHA decided that an area is merely “hard to reach” rather than besieged if it has received an aid convoy in the last three months, regardless of whether the supplies are sufficient for one month, let alone three.

One doesn’t need to travel far from Damascus to see how little a distinction there often is between a “hard to reach” and a “besieged” area. Madaya, a small town of 42,000 civilians, is less than an hour’s drive northeast from the Four Seasons. Once known to Syrians as a holiday resort, it is now synonymous with the suffering and starvation inflicted by the Syrian army and its militia allies. The severe malnutrition facing the people of Madaya—23 had died by January 7, according to Médecins Sans Frontières—won the city intense international focus, but OCHA did not list it as a besieged area until February.

Of the 1.1 million people who are likely living under siege conditions in Syria, more than 900,000 are victims of pro-government forces. The largest such population is in Eastern Ghouta, where half a million civilians have languished since November 2012. In Duma, the principal city of Eastern Ghouta and a mere ten miles northeast of Damascus, children take turns eating every other day. Meanwhile, the Islamic State (also known as ISIS) has cut off some 180,000 people in government-held Deir ez-Zor, in northeastern Syria. And other armed opposition groups have blocked regular humanitarian access to the northwestern towns of Foua and Kefraya, which have a combined population of about 15,000, although these cities have received several airdrops from the government.

Between starvation, direct attacks, and destroyed health infrastructure, hundreds of thousands of Syrians have died as a result of the war and nearly 1.9 million have been wounded or disabled. Since 2011, Syrian life expectancy has dropped a shocking 15 years—from 70.5 to 55.4. That is a shorter life span than even civilians in Afghanistan and Sudan expect today. Because they have prioritized working with the Assad regime over gaining access to those in most acute need, OCHA and other UN agencies such as the World Health Organization, the World Food Program, and UNICEF, bear some responsibility for this tragedy. If UN agencies such as OCHA do not rethink the way they provide funding and aid to Damascus, the problem will only intensify.

A Syrian Arab Red Crescent aid convoy wait to enter the town of Madaya, near Damascus, Syria, February 17, 2016.
A Syrian Arab Red Crescent aid convoy wait to enter the town of Madaya, near Damascus, Syria, February 17, 2016.
Omar Sanadiki / Reuters


The siege of Madaya and several other small nearby towns began gradually in July 2015, a collective punishment imposed in response to 500 rebel fighters who refused to give up in nearby Zabadani. After four years of war, Madaya’s children were already compromised, semistarved and undervaccinated. To try to open humanitarian access to Madaya, in September 2015, armed forces struck a deal with government forces: if the government allowed aid to Madaya, the opposition would allow aid in to the pro-government towns of Foua and Kefraya.

Immediately after the agreement, on September 23, Hezbollah militia members, who are allied with the Syrian government, began planting some 4,500 land mines in the fields to the west of Madaya. The apparent motive was to prevent the government from losing its leverage if too many civilians escaped. Indeed, although most people think of sieges as being patrolled primarily by soldiers, the soldiers, since they cannot be everywhere, sometimes use land mines to fill in gaps. For Madayans, the choice thus became a slow death of disease and starvation or a fast death from sniper fire or land mines.

On September 27, 2015, 12-year-old Claudia Alshimali’s mother confronted that awful choice. Facing rising food prices—one pound of rice cost roughly $100 at the time—she wanted to get to Damascus before winter. She and her daughter left in plain sight, asking permission from the officer manning the Syrian army checkpoint. Under the laws of war, civilians must be allowed to leave, but the officer refused. When Claudia and her mother tried to run away from the checkpoint toward the main road, the soldiers opened fire on them. Her mother escaped, but Claudia was badly wounded. She might have survived, but the officers left her to bleed to death.

There is no doctor in Madaya. Abdi Ahmad, a paramedic trained in emergency medicine, has become Madaya’s doctor by default. He recounted how when his friend Hassan Assamra saw the injured girl, he tried to reach her by crossing through a nearby field. That’s when he stepped on a mine that destroyed his left leg. Abdi was forced to amputate it while Claudia died alone in the dust. Hassan, only 30 years old, was Madaya’s only physical therapist. There is now no one to help him with his own postamputation rehabilitation, let alone help other victims.

On October 19, as a result of the September deal, convoys of aid were finally delivered to the Madaya-Zabadani area, as well as to Foua and Kefraya. OCHA organized deliveries to Foua and Kefraya from UN warehouses in Turkey, but the aid for Madaya-Zabadani ended up coming from warehouses under the purview of the Syrian government in Damascus. No food was sent to Zabadani, just some 250 hygiene kits—soap and shaving cream. Meanwhile, damaged medical supplies and expired food went to Madaya. Within 48 hours, hundreds of Madayan children were suffering from vomiting, diarrhea, or both. It was later revealed that 320 out of 650 boxes of high-energy biscuits had expired. The Syrian government said nothing, and OCHA called it human error.

It is likely that the widespread illness was due to the biscuits, but not because they had expired. Rather, the children’s symptoms were consistent with refeeding syndrome, a state of severe metabolic imbalance that occurs when people who have been deprived of nutrition, vitamins, and minerals are suddenly given carbohydrates without any extra nutritional support or medical care. Malnutrition is especially catastrophic for children, as sustained deprivation halts not only physical but also emotional and neurologic development.

A man gives medical assistance to an injured man as two wounded children wait nearby at a field hospital after what activists said was an air strike by forces of Syria's President Bashar al-Assad in the Duma neighborhood of Damascus, February 2, 2015.
A man gives medical assistance to an injured man as two wounded children wait nearby at a field hospital after what activists said was an air strike by forces of Syria's President Bashar al-Assad in the Duma neighborhood of Damascus, February 2, 2015.
Mohammed Badra / Reuters


Pressure on the international community to do something more increased after January 8, when Médecins Sans Frontières issued a report stating that in addition to the 23 people who had died of extreme hunger since December 1, 2015, 250 more were in a critical state. On January 11, the Syrian government finally allowed another OCHA-sponsored relief convoy through the siege to supply some food and health supplies to Madaya. But it was too late for 12-year-old Mohamad Alloush, who earlier the same day lost both legs after stepping on a mine while he was gathering weeds to feed his family and firewood to heat their home.

Even after the January 11 convoy, five more people died of extreme starvation. Making matters worse, in mid-January, Hezbollah planted another 5,000 mines around Madaya’s borders.

For some time, the residents of Madaya have been trying to clear the mines themselves. A leader of this effort, first begun in September 2015, was Majed, who graduated in 2011 with an economics degree before returning to his hometown of Madaya. He explained how they worked. “We used very primitive tools—six-millimeter iron bars, dress wear to protect our legs and faces, and rubber tires and hooks to explode mines away from us,” he told me.

On February 27, shortly after midnight (to avoid snipers) and taking advantage of the partial cease-fire negotiated by U.S. Secretary of State John Kerry and Russian Foreign Minister Sergey Lavrov, Majed and several volunteers set out for the fields. “We were very nervous due to the random location of these mines, but when we made it there, we were surprised to see a group of young men—also civilians—already there, and who had started working on removing some of these land mines.”

Unfortunately, some of the mines were booby-trapped to deter the inexperienced from attempting removal. One of Majed’s teammates lost his right leg when he lifted a mine and triggered a grenade hidden beneath. Persevering, the volunteers have cleared some 700 PMN-2 antipersonnel mines since the cease-fire.

But 700 isn’t enough. From September 27, 2015, through March 23, 2016, Madaya’s civilians suffered 83 deaths and 60 serious wounds. Thirty-one have died from sniper fire, starting with Claudia. Nine have died from land mine explosions, 43 from starvation, and one from kidney failure. In addition, at least ten civilians who strayed into unmarked minefields have suffered serious injuries requiring amputations.

To date, all but one of the amputees is trapped in Madaya, unable to receive appropriate physiotherapy, let alone a prosthetic limb. The cease-fire has so far allowed the evacuation of only two wounded people. And 5.1 million Syrians still live in areas contaminated by land mines, improvised explosive devices, and unexploded cluster bomb submunitions.

Turkish Kurds throw water bottles to the Syrian side over the Turkish-Syrian border fence, near the southeastern town of Suruc in Sanliurfa province September 26, 2014.
Turkish Kurds throw water bottles to the Syrian side over the Turkish-Syrian border fence, near the southeastern town of Suruc in Sanliurfa province September 26, 2014.
Murad Sezer / Reuters


Well before the minefields were sown around Madaya, the Syrian army was planting them along the country’s borders with Lebanon and Turkey. There are roughly 700,000 along the Turkish-Syrian border alone. Between October 2014 and October 2015, land mines killed 67 civilians and 24 combatants.

In recognition of the widespread threat to civilians, the UN Mine Action Service (UNMAS) opened an office in Damascus in 2012 to begin a mine removal program. The office was forced to close within six months, though, because the Syrian Foreign Ministry denied visas for its staff.

In 2014, after the UN Security Council authorized cross-border humanitarian operations regardless of the consent of the Syrian government, OCHA asked UNMAS to deploy a team to southern Turkey. Working with various partners, UNMAS said it helped to destroy “364 items of explosive remnants of war, weighing almost seven tons. Through this effort 17 houses, three schools, one hospital, four playgrounds, and 21 shops were searched, cleared, and returned to the community.”

UNMAS was meant then to go on to Aleppo and Idlib—plans that were outlined in OCHA’s 2016 draft Humanitarian Response Plan. Soon after, $32 million in funding for the work was secured. But the Syrian government, after reviewing the draft, insisted that mine clearance be removed, and Kennedy and El Hillo agreed. This was not the Syrian government’s only amendment, but it was certainly one of the more egregious. It also had the effect of stopping UNMAS cross-border work from Turkey.

Stephen O’Brien, a British lawyer who heads OCHA, defended his agency by claiming that mine clearance is illegal under Syrian law. “Like it or not,” he said at the World Economic Forum in Davos in January 2016, “in Syria they have a law, and their law is anyone who is involved in removing unexploded ordnance . . . [is] regarded as a combatant. It is a law of Syria. And so [mine clearance] had to be removed because it was contrary to Syrian law.”

Yet despite O’Brien’s convenient justification, there is no such law in Syria. Moreover, even though Syria is not a party to the international Mine Ban Treaty, the government and all armed forces are still bound by customary international law, which prohibits indiscriminate warfare and mandates taking all feasible steps to protect civilian life. And of course, whatever law Damascus promulgates is of little relevance to the areas of the country that are outside government control where demining is also needed. As noted, the UN Security Council has authorized humanitarian activities to cross the Turkish border to reach these areas regardless of whether Damascus offers permission—but that was not enough for OCHA to keep demining in its work plan.

As the rest of the world prevaricates, besieged Syrians continue to risk life and limb in their desperation to find food. The few convoys allowed since the cease-fire have only marginally alleviated the misery facing Syrian civilians. At a time when the cease-fire should allow civilians to move more freely, mines remain an obstacle to schooling, agriculture, food security, hospitals, and medical care. The cease-fire has opened the door for some mine clearance, but OCHA’s prioritization of good relations with the Syrian government has eliminated much-needed programming and funding. Skillful manipulation by the Syrian government means that whatever utility OCHA may still have in Damascus is in danger of being overwhelmed by complicity in Assad’s anticivilian war strategies.

It is time for a renewed effort to tackle the sieges and land mines. Syria has enough crippled kids already. 


On March 29, three young boys from Madaya became the latest casualties of the Syrian government’s anti-civilian strategy.  Two little brothers, Ali and Wassim Dalati, just six and seven years old, and their friend, Josef Ammar, also seven, were on their way home from school when they found what they thought was a new toy close to a checkpoint where they used to scavenge for cans of food tossed away by the Hezbollah officers stationed there. On seeing them pick up a green cylinder, a neighbor yelled at them to drop it. Frightened, the boys threw it to the ground. It exploded. Josef, who had already lost his father to a landmine in Zabadani in July 2015, was torn apart and died immediately. Wassim’s legs were destroyed, while Ali suffered a head injury and abdominal bleeding. They were rushed to Madaya’s tiny hospital, but Wassim died within two hours. Ali, who was expected to survive his injuries, was denied medical evacuation to Damascus in an obscene adherence to the tit-for-tat September deal: because there was no one to evacuate from Foua or Kefraya, Hezbollah refused to let the local branch of the Red Crescent take him. Ali died in the early hours of March 30.  A few hours later, the three playmates were buried together in a grave dug by Ali’s and Wassim’s father. 

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  • ANNIE SPARROW, a critical care pediatrician and public health expert, is an Assistant Professor at the Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai Hospital in New York City.
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