Severe acute malnutrition is one of the most serious forms of hunger and if it is left untreated, particularly in young children, the consequences of acute malnutrition are particularly severe and reach far into the future. Good nutrition is the foundation for every child’s growth and development, and without a healthy diet and adequate quantities of food, the consequences manifest in different forms as demonstrated by No Wasted Lives.

Malnutrition is an umbrella term which includes micro-nutrient deficiencies and deficiency diseases, obesity, chronic malnutrition (stunted growth), and acute malnutrition (wasting). Stunting can badly impact physical and cognitive growth affecting children’s development at school while children under 5 who suffer both stunting and wasting are more likely to die as their immune systems are severely weakened and are less resistant to common childhood diseases. Malnutrition has become one of the Syrian civil war’s deadliest legacies.

HUNGER AS A WEAPON OF WAR

Against the backdrop of barrel bombs, chemical weapons, indiscriminate bombardment by air and artillery and state-sponsored massacres, the use of food and hunger as a weapon of war to terrorise and subdue rebellion has been central to the Assad regime’s strategy to crush the Syrian Revolution which ignited in 2011, and caused widespread malnutrition.

Besieged cities have made headlines through the war and evidence shows that starvation is being used as a weapon of war. Two-and-a-half million people, or ten per cent of the pre-war Syrian population, have been victims of sieges including areas such as Eastern Ghouta, Idlib, western Aleppo, Yarmouk, Daraya and Madaya. Starvation has been in the government’s toolbox to break the opposition regularly throughout the conflict.

As a consequence near-famine conditions have been widespread since the outbreak of conflict. In Madaya, families were eating leaves, pets, grasses and water flavoured with spices to survive. In December 2017, UNICEF reported that 11.9 per cent of children in Eastern Ghouta were suffering from acute malnutrition, the highest rate recorded in Syria in the entire war.

In Madaya and Eastern Ghouta, and displacement camps such as Rukban and Al-Hol in eastern Syria, haunting images of malnourished children have emerged. “These harrowing images represent the tip of the iceberg,” said Phillip Luther, Director of the Middle East and North Africa at the human rights group Amnesty International. “Syrians are suffering and dying across the country because starvation is being used as a weapon of war.”

This tactic has continued unabated in Idlib throughout 2019 and 2020. In July and October 2019, Channel 4 published two reports on children scavenging through rubbish to find food in the besieged city of Idlib and the strategic burning of farmland by the Syrian army to starve opposition and their populations into submission.

The Assad regime and the opposition have also targeted agricultural infrastructure destroying irrigation canals and grain depots. In 2016, it was reported that storage facilities of state seeds had been so badly damaged across the country that it had reduced seed distribution to farmers across the country to one-tenth of the amount before the war.

Food markets have been targeted regularly by air-power and continue to be hit by strikes to this day. On 20th August 2015, four strikes by Syrian aircraft on a marketplace in the town of Douma killed over 112 civilians and wounded over 550 men, women and children. “I entered the market and the corpses were scattered everywhere, human remains were thrown on the produce and vegetables, and under every box of tomatoes was a corpse or part of a corpse.” The Douma market bombing was one of the deadliest airstrikes of the entire war.

In 2017, 84 people were killed when an Idlib marketplace and police station were hit by Russian or regime bombers. In July 2019, Russian air attacks hit a vegetable market killing 36 civilians in Maarat al-Numan. In December 2019, 10 civilians were killed in an airstrike on a vegetable market in Idlib. In January 2020, this was followed up by another series of airstrikes on a market which killed 21 civilians in the besieged town. With marketplaces regularly in the shadow of explosive violence, it is little wonder that men, women and children- particularly those living in besieged enclaves - have been unable to get the food for a healthy diet. Without a proper diet and healthy food, different forms of malnutrition inevitably follow.

DECIMATING SYRIA’S HEALTHCARE SYSTEM, TARGETING AID WORKERS

While siege tactics have led the headlines, the use of explosive weaponry has been integral to driving up child malnutrition in Syria in several different ways and has predominantly come through the destruction of the country’s economic infrastructure, its agro-industry and, most importantly, hospitals. At the World Health Organisation, guidelines specify that children with severe acute malnutrition who do not have health complications that require hospitalisation must receive special, high-energy food and antibiotics to treat the infection. Families often need guidance to administer treatment and access to hospitals.

The systematic targeting of Syria’s healthcare system, alongside the use of chemical weapons, is one of the grimiest stains of the civil war and has hampered the ability of medical personnel to treat malnutrition (a process which doesn’t take long to diagnose but months to treat). Between 2011-2019, the Syrian government assassinated, bombed, and tortured to death over 900 hundred medical personnel (54 per cent of these deaths a result of shelling and aerial bombings). In Aleppo alone, 95 per cent of physicians fled the country to avoid a similar fate to their colleagues. Out of 588 attacks on 350 separate facilities, 530 have been conducted by the Syrian army and its allies and in 83 incidents, barrel bombs were deployed by the regime to target hospitals.

The ferocity of the fighting in Eastern Ghouta, for example, ‘severely restricted children’s access to health and nutrition services.’ As civilians struggle to access medical and treatment centres, either because they are too far away or difficult to access from IDP camps or because a walk to the hospital can mean death by an airstrike (or medical facilities have been destroyed by airstrikes), aid workers (international and local) are also struggling to reach homes to treat malnutrition. Ready-to-use therapeutic food (RUTF) is one of the most effective ways to treat malnutrition and a method which allow patients to be treated at home. However, aid workers are frequently unable to reach those who are malnourished because they are under siege or because of explosive violence during ongoing offensives.

Food supplies have been targeted by airpower, the starkest example being the Russian aerial attack on a humanitarian aid convoy belonging to the Syrian Red Crescent trucks which were carrying UN food supplies to a rural area west of Aleppo city. The airstrike decimated the convoy carrying food and medicine and killed over twenty aid workers. Without supplies such as RUTF being delivered due to airstrikes or conditions too dangerous to access malnourished children with medicine, malnutrition cannot be effectively treated in the home. With medical facilities being bombarded, complications cannot be addressed and assessments cannot be conducted.

Pregnant and nursing mothers are also vulnerable. In emergencies, pregnant women, nursing mothers, and children under the age of five are extremely vulnerable to malnutrition. If young mothers also do not have enough food to eat and suffer from malnutrition, their children will not be able to breastfeed because they do not have enough to eat to produce milk. In 2017 it was reported by the Department for International Development that iron deficiency anaemia was highly prevalent among 24 per cent of pregnant or lactating women in Syria while 7.8 per cent of young mothers were suffering from acute malnutrition.

This impacts child health and development benefits of breastfeeding which range from fewer infections, increased cognitive ability, and probable longer-term protection against diabetes and obesity. As Action Against Hunger’s work demonstrates in Bangladesh, Myanmar and South Sudan, trauma and mental health can also play a key role in creating malnutrition. “Psychological first aid must always be closely linked with nutrition programmes in large-scale emergencies,” said Farhana Rahman, Mental Health Director at Action Against Hunger Bangladesh responding to the Rohingya crisis. “If you are stressed you will not be able to eat, sleep or maintain a healthy life. It’s that simple.”

According to the World Health Organisation, more than half of the Syrians need mental health services due to ongoing violence. This will almost certainly include young mothers and pregnant women whose newborn children depend on them for good nutrition. In Eastern Ghouta during the regime offensive when malnutrition spiked to its highest level of war, anxiety and trauma was clearly inhibiting the ability of mothers to support their children’s nutrition needs. “(Many) mothers are not able to breastfeed or nurse their children,” said Juliette Touma, UNICEF’s chief of communications in the Middle East. “They’re either malnourished themselves, or they are stressed or tired because of the violence.”

With health services, markets (which supply fresh food, vegetable and dairy products essential for a balanced diet), doctors and aid workers being shelled by artillery, aircraft and helicopters, and humanitarian workers often denied access the most vulnerable in their homes directly, and the terror of explosive, it has pushed up malnutrition rates in war-zones.

FAMINE? - THE CLIMAX OF SYRIA’S MALNUTRITION CRISIS

Syria’s malnutrition crisis is one which is worsening with each passing year of war. By the beginning of 2020, food insecurity has remained at critical levels, and been compounded by the total collapse of the Syrian currency and ongoing sanctions imposed by foreign powers. According to the Famine Early Warning Systems Network, ‘high food prices were predicted to continue to drive extreme levels of food insecurity, and that famine would be likely in the prolonged absence of humanitarian food assistance.’

It has been a winter of terror in Syria. The Assad regime is tightening his grip on the remaining enclaves of the Syrian opposition in north-western Syria in the Idlib governate. With the offensive has come the trademark tactics to brutalise the Syrian population including the indiscriminate use of explosive weaponry in urban and rural areas. In February 2019, Kenneth Roth, Executive Director of Human Rights Watch tweeted that ‘Russia-backed military campaign in Syria’s Idlib province in recent weeks “has included the bombing of heavily populated areas & civilian infrastructure including hospitals and markets. In January alone, 53 health facilities have suspended work in Idlib.”’ The cycle causing malnutrition has continued.

According to the International Rescue Committee the Idlib offensive - spearheaded by Assad’s army and Iranian paramilitaries and supported by Russian airpower - is ‘triggering the largest displacement in the country’s nine-year-old war’ with an estimated one million men, women and children estimated to have been displaced. According to the World Food Programme, eighty per cent of those who have fled have been women and children, traumatised by the murderous air raids of the regime. In the last week alone, dozens of children have perished due to the terrible conditions within the displacement camps.

Stranded on the frost-bitten slopes along the Turkish border, a silent killer has entered the displacement camps: the threat of malnutrition. "The situation is 20 times worse than what it was last year. And over the span of last year, we had 1.2 million people displaced," said one aid worker to Al-Jazeera. Syria Relief and Development, a charity supporting Idlib’s internally displaced persons (IDPs), have warned that famine on the scale of the one in Yemen could hit northwest Syria, an indirect consequence of malnutrition and hunger in the camps.

Though it is not inevitable, the outbreak of famine in Syria, a direct consequence of Assad’s war machine targeting civilian populations with explosive weapons, would be the climax of the regime’s war on the country’s food security and child nutrition. The short-term impact of famine would be catastrophic in affected areas, while in the long-term the impact of malnutrition, exacerbated by explosive violence, will have a severe impact on the future of the country’s children.