Five months after a de-escalation deal curbed violence in the besieged, opposition-held suburbs east of Damascus, children in the encircled rebel enclave are now dying of complications related to acute malnutrition.

Approximately 1,200 children are suffering from acute malnutrition in East Ghouta, Juliette Touma, a spokeswoman for UNICEF told the BBC earlier this week.



Trapped behind a four-year regime siege, East Ghouta’s estimated 400,000 residents are facing major shortages of food and baby formula after the Syrian government tightened its encirclement of the rebel stronghold last spring.

In March, an offensive by regime forces closed down underground smuggling tunnels that rebels had used to bring food, fuel and other goods into the pocket—a major blow to the opposition-held enclave’s food security.

Then, three months ago, East Ghouta lost its last lifeline when the regime-run al-Wafideen checkpoint—used by war profiteers to sell food behind the siege—halted operations.

Without smuggling tunnels and the trade checkpoint, the siege has “greatly intensified over the past few months,” says Mohammad Katoob, a Syrian doctor with the Syrian American Medical Society (SAMS), an organization that supports and operates several medical facilities in East Ghouta.

Hala, 2, weighs just 9lbs. Oct. 25. Photo courtesy of Abdulmonam Essa/AFP.

“Cases of moderate malnutrition are devolving into acute malnutrition,” Katoob tells Syria Direct’s Noura Hourani. “This is new—and it has emerged dramatically.”

On Wednesday, the UN released a statement warning that Eastern Ghouta may have “entered one of the most difficult periods” since the siege began in 2013.

“With each passing day we lose more of our medical capacity and supplies,” says Katoob.



“We expect more deaths in the days to come.”



Q: How many children are suffering from malnutrition in East Ghouta, currently? How is this condition manifesting?

The siege of East Ghouta is not new, but it has greatly intensified over the past few months after we lost the [smuggling] tunnels and the [Wafideen] trade crossing. The entry of goods has vastly decreased and—in some cases—stopped altogether. So malnutrition itself is not new, nor a surprise.

What is happening in Ghouta today, though, is that cases of moderate malnutrition are devolving into acute malnutrition. This is new, and has emerged dramatically.

When moderate malnutrition becomes acute, it weakens the body’s immune system. People catch secondary illnesses because of this lack of resistance, and this is the cause of the recent deaths. Malnutrition was not the direct cause of the two infants who died last week. If it had been just malnutrition, it would not have been particularly complicated, but there were secondary issues.

The problem is when malnutrition is accompanied by malabsorption or other issues—whether in children or adults. When that happens, treatment becomes very complicated. With our limited capacities here in East Ghouta, the patient's condition can deteriorate due to inflammation or a single swelling.

Currently, with the severe siege and insane increase of prices in East Ghouta, many people are not able to buy the food they need even if it is available. Especially in the winter, people may not be able to get carbohydrates or starches. This is one reason for chronic malnutrition.

Q: What age groups are you seeing malnutrition in?

When we raise the alarm about malnutrition, we are most worried about the age group between six months and five years. Children younger than that—especially if they are breastfed naturally—are not usually hit by malnutrition unless they suffer from malabsorption.

East Ghouta has cow’s milk, which can sometimes help to alleviate the severity of malnutrition. Disaster happens when a nursing infant cannot consume cow milk, combined with the lack of food diversity or intake [of the mother].

There is a statistic from the Syria Relief Network [an umbrella organizing body for 60 Syrian NGOs] that 72 percent of East Ghouta children under five years of age need food support. This doesn’t mean a food parcel, but rather nutritional supplements or baby formula.

Q: What is the role of humanitarian organizations to put pressure for goods to be brought in or the siege to be broken?

There are two kinds of organizations: NGOs like us [SAMS] and United Nations agencies. Those agencies have access and offices inside Syria. They can apply pressure, but the regime obstructs their work. The persistent problem here in Syria is the linking of humanitarian issues with truces and de-escalation agreements.

It is as though Syrian people have no rights. There should be a humanitarian side outside of these agreements so that a person can have their right to food, health and all humanitarian needs regardless of political background.

Even when humanitarian issues are tied to the agreements, they are not implemented. The crossings are not open, the siege has not ended, there has been no ceasefire. We as an organization are trying to exert pressure by various means, either through the media to clarify what is happening and present statistics, or through official channels with the United Nations and our meetings with state representatives.

Q: What options does Ghouta have, currently? Do you believe that we will see more deaths in the days to come?

We in Ghouta are depending on supplies that we stored up [prior to the Wafideen crossing closure] this past June. Unfortunately, those stores are beginning to run out, especially the medical supplies. As a result, we are starting to see cases like these.

As the siege drags on, with each passing day we lose more of our medical capacity and supplies. There is no real treatment for people with cancer, for example. We no longer even have painkillers to give them.

Over the past three months, one person has died every week as a result of the siege. That is, patients who could have easily recovered if the medicine had been available. These are simple cases that could certainly medically recover. We expect more deaths in the days to come.