Driving towards Madaya in a convoy that snaked along the Damascus highway for hundreds of metres, a huge knot formed in the pit of my stomach. Not knowing what we would find there, and remembering the harrowing images of emaciated children pleading with their eyes for some respite from this siege, it was hard not to be worried -- the type of worry that seeps into your bones.
As we made our way through the towns just before Madaya, the silence was eerie. Row upon row of abandoned restaurants, shops with shutters rusted closed, homes padlocked, overgrown gardens and thirsty shrubs that had long turned brown. The emptiness and neglect were stark.
After hours of waiting at checking points, we slowly moved into Madaya itself, as the sun started to set. I was immediately struck by what I saw, wondering if I was in the right place. As we drove through the town ever so slowly, UN cars with flags flying high followed by truck after truck of lifesaving supplies, they all came, despite the late hour. Children everywhere -- running beside the convoy, their excitement irrepressible. Women watching from balconies, young men standing staunch on street corners, suspicious but slightly relieved that we were there. All of them escorting the precious cargo along its way.
As soon as we disembarked, the unloading of supplies started. The UNICEF team headed straight for the makeshift health clinic. Like the piped piper, the women and children followed, calling the name of the UNICEF doctor they remembered from convoys past, "Dr Rajia! Dr Rajia!" They were so happy to see her again, hoping she would bring medicine... and some answers. They formed a line outside the clinic, willing to wait as long it took to see her.
One of the doctors told us that he has now resorted to using hair gel for ultrasounds as he no longer has the medical gel to perform this most basic of tests.
Patient after patient was screened by Dr Rajia, and all of them sharing stories. Parents whose children had stopped eating because their bodies could no longer tolerate only rice and beans. Children who could no longer walk straight because of the lack of Vitamin D and micronutrients that had riddled their bones with rickets, or who had stopped growing entirely, stunted from lack of essential vitamins. One mother showed us her baby's bottle filled with rice water -- the teat so worn it had to be sewn back to together. "Look at what I am feeding my child" she said.
Almost everyone we spoke to asked for protein -- meat, eggs, milk, vegetables -- something more to sustain themselves than the dry goods that were available. One mother explained that every time her child now smells boiled burgal, she starts to cry.
The doctor reported an increase in miscarriages, 10 cases in the last six months, because of the nutritional status of mothers. Over the last year alone, he has had to perform over 60 caesarian sections. This number was unheard of before the crisis, she told us. But women no longer have the strength for childbirth, and many pregnancies go over term, again because of the poor health of pregnant women.
We did not see widespread malnutrition as we had during past visits. This time it wasn't the physical emaciation that struck us, but the psychological emaciation. The doctors reported 12 cases of attempted suicide, eight of them women. The prolonged siege was pushing people to the brink -- some seeing death as the only way out.
The local health worker recounted the stories: a mother of five who felt she could no longer feed and care for her children; a high school student who wasn't allowed to leave Madaya to take his national exams; a 21-year-old newly-wed who had lost her husband in the violence and couldn't find the strength to continue alone; a 16-year-old girl who could not see a future for herself in the hell that surrounded her. All of them tried to take their own lives -- a last resort -- the only possible escape from their daily horror. It was very clear that the coping mechanisms of people are starting to erode -- their resilience truly tested in the face of a siege that they fear will have no end.
The doctors and health workers, though, demonstrated true resilience. Working in appalling conditions, without some of the most basic equipment and supplies. One of the doctors told us that he has now resorted to using hair gel for ultrasounds as he no longer has the medical gel to perform this most basic of tests. He showed us his operating theatre. A mish-mash of plastic draws, old wooden shelves, and surgical supplies left on open trays that he sterilizes using flames because he has run out of alcohol. And yet he continues, because not to do so is just not an option.
And amidst all of this suffering, I met a 10-year-old girl. Under-nourished but smiling at Dr Rajia, so pleased to see her again. I asked her about school and what she wanted to do when she grew up -- she looked at me with so much hope in those big brown eyes and said: "I want to work with you." She hovered around the clinic until the last patient was screened, and as we walked up the stairs and out of the basement clinic she took my hand and held it tight. We made our way back into the street and she disappeared with her mum into the darkness. I pray that I will see her again in a Madaya that will one day be open again.
Mirna Yacoub is the Deputy Representative for UNICEF, Syria
To learn more about UNICEF's work in Syria, click here
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The plight of Syrians besieged in the town of Madaya prompted an international humanitarian response (AP Photo) Hunger, starvation, and extreme malnourishment present existential threats to millions of Syria's most vulnerable people. The young, the elderly, and the infirm are all particularly susceptible to the effects of malnutrition, which can stunt the growth of children, and exacerbate chronic medical conditions. Unicef deputy director Lily Caprani told HuffPost UK about the effects long-term malnourishment are having as the Syrian conflict enters its fifth year. She said: "There’s hunger in the short term, and then malnutrition over the longer term severely and in some cases irreversibly damages children’s development, so a child who at the age of two or three is undernourished can physical stop growing. “Unfortunately there are some cases where that cannot be undone. We’re trying to stop getting it to that stage." Unicef continues to work in Syria, and it estimates it has helped the majority of those who need help in accessible areas. That still leaves as many as two million out of reach of aid, however. Towns which are besieged by fighting are particularly difficult to access. In one example, the situation in the Syrian town of Madaya, north west of Damascus, had become so dire that the UN estimated 400 residents needed to be immediately evacuated to receive life-saving treatment. Their conditions related to extreme malnourishment and starvation, as well as medical conditions.
Syrian boys play with snow following a storm in the northern Syrian city of Aleppo on January 5 Exposure to the elements is become a concern for aid agencies operating in and around Syria. Harsh winters bring snow, ice, and chilling winds - making for harrowing conditions in houses lacking electricity and the refugee camps bordering on vast, desolate landscapes. "One of the key things we worry about every year in that on top of everything else, we now have extreme cold," Lily Caprani of Unicef UK says, "Although we're doing everything we can to them, they're living in tents, in containers." The organisation is leading a campaign to keep children warm this winter with hats, gloves and scalfs. "Many of the refugees in... countries such as Jordan and Lebanon live in terrible conditions and are struggling to find warmth as temperatures fall," Robert Mardini, director for the Near and Middle East with the International Committee of the Red Cross, told Al Jazeera. "They live with the uncertainty of not knowing what tomorrow will bring, or even if they will ever make it back home one day."
Syrians searching for survivors in the rubble of destroyed buildings following the barrel bomb-attacks of Syrian air forces on February 2, 2014, in Aleppo, Syria. Barrel bombs continue to plague Syrian cities. The improvised devices are thrown from transport helicopters, without the ability to hit specific targets. According to the Syrian Network for Human Rights, the number of civilains killed by Syrian regime barrel bombs outnumbers those slain by the so-called Islamic State and al-Qaeda. Jeremy Binnie, Middle East editor for IHS Jane's Defence Weekly, told HuffPost UK that the bombs were developed due to either a lack of weaponry or aircraft around a year or so into the current conflict. He said: “While early ones appeared to be similar in size to oil barrels, the ones that have been seen generally have a smaller diameter. “They were first seen in the summer of 2012. “They are a way of turning the Syrian air force’s Mi-8/17 helicopters into attack aircraft as the improvised bombs can be rolled out the rear cargo doors.” “The bombs are capable of destroying buildings and killing people, but almost certainly have less explosive power than mass-produced aircraft bombs of similar size."
A Russian bomber drops bombs on a target. Russia has unleashed another barrage of airstrikes against targets in Syria Airstrikes from foreign forces continue to pose a threat to civilian life - however unintended this may be. In December, at least 26 people were believed to have been killed following US-led airstrikes attacking suspected Isis positions. The Guardian reported Rami Abdel Rahman of the Syrian Observatory for Human Rights as saying Isis is in control of Al-Khan but is only on its outskirts, “which is why all of the deaths were civilians”. The US military command said it was investigating the claims. Britain's Royal Air Force, which received Parliamentary authority to commence airstrikes last year, says it is able to say no civilians have died as a result of its recent airstrikes in Syria which are planned meticulously to prevent collateral damage.
A health worker marks the thumb of a Syrian child after giving him polio vaccine (File Photo) Dirty water and the resulting disease pose a continued threat to Syrians living in increasingly unsanitary conditions. Unicef is one of a number of aid agencies working to mitigate the risks, but even it admits that millions of Syrian children and adults who continue to be at risk in areas that cannot be easily reached. While the threat continues to be high - disease is one of the areas of success for agencies trying hard to prevent a public health disaster dovetailing with the fierce conflict. Lily Caprani of Unicef told HuffPost UK: "We’re making sure children and the vulnerable are immunized against waterborne disease, because we know they are going to be exposed to disease so we make sure they’re going to be protected. “This can help prevent a public health disaster. One of the very few pieces of good news is that you would expect the resurgence of disease and infections we would normally not see. “But because we’ve managed to immunize we’ve prevented this. There have been no new cases of polio since January 2014 and that’s short of a miracle. "It’s relatively cheap to do - it doesn’t cost a lot of money and it prevents the snowball effect of a public health emergency." Nonetheless, the shocking state of health uncovered at the besieged town of Madaya in January points towards localised medical emergencies being commonplace in some areas in the country.
A visitor looks at photographs in the 'Caesar's Photos: Inside Syria's Secret Prisons', a collection of photographs smuggled out of Syria last year Torture and execution remain a threat to civilian life throughout Syria, with hundreds allegedly killed at the hands of President Assad's regime alone. Syria has systematically tortured and executed 11,000 of its citizens in the three-year war, according to a report by former war crimes prosecutors, who compared the bodies they saw to images of Nazi death camp victims. Meanwhile the so-called Islamic State has been adept at publicising its regime's torture and execution, even publishing reports in its own magazine, with countless Syrians and scores of foreigners killed in the now signature orange jumpsuits. In January, the Syrian Observatory of Human Rights reported that an Islamic State militant executed his own mother, after she encouraged him to leave the terror group.
Violence and exploitation resulting from the break down of Syrian society present a real threat to the lives of adults and children alike, whilst kidnapping remains a tactic of fear used by militants. There are countless examples of violence between warring factions spilling over into civilian communities, wounding and killing innocent people. Unicef's experience of conflict emergencies across the world has led it to the conclusion that education can protect children from violence and exploitation. Lily Caprani, UK deputy director, told HuffPost UK: "If children are in education, they’re in a safe space. If children are in a safe environment with safe people, the risks of violence and exploitation are lower. "This protects children from adults who might not have their best interests at heart." Kidnapping by Islamic State militants continues to present a real threat to civilian life. Last year, hundreds of innocent people were taken by the group amid mounting international calls for the release of those abducted.
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