Ms Jane-Ann McKenna:

I thank the committee for inviting me to today's meeting to discuss the humanitarian impact of the conflict in Syria and MSF's response. I have just returned from Jordan and northern Iraq where I conducted an assessment for MSF of the overall humanitarian response in the region for Syrian refugees. Thousands continue to cross the border almost daily and all actors are trying to scale up their activities to try to meet the increasing needs. Today, I will focus mainly on MSF's response inside Syria, but I will be happy to address any questions regarding the response to the Syrian refugees.

Across Syria there are enclaves surrounded by intense fighting where virtually no aid is reaching the people trapped inside. Our teams on the ground have seen at first hand the horrors of living under siege, where, for example, water is cut off and snipers fire at anyone who tries to access the only well with water left in the area and where food is scare and the constant shelling is intense. People are living in extreme fear and in abominable conditions. The wounded and sick face near insurmountable obstacles when trying to access health care due to the relentless bombings and the targeting and destruction of Syria's health system.

The medical system, like the rest of Syrian society, has been under siege during the conflict and is no longer capable of responding to the acute and chronic medical needs of the Syrian people. Of the 91 public hospitals across the country, 60% have been damaged or completely destroyed. Doctors have fled the country in huge numbers. Among those who remain are small numbers of medical specialists, doctors-in-training and surgeons with little or no experience in operating on war-related injuries. Dentists are performing minor surgeries, pharmacists are treating patients and young people are volunteering to work as nurses. MSF is providing emergency surgical care to victims of violence and trauma in six hospital across three governments in northern Syria.

I will refer to an extract written by one of our Irish doctors who has just returned from working for two months in our hospital in Idlib, which reflects the reality of the situation. He wrote:

And then August hit and our project quickly turned to trauma management. Fighting intensified, villages were bombed and casualties, fighters and civilians, flooded in. Within two weeks we launched nine mass casualty incidents. This is when the influx of the wounded exceeds the capacity of our hospital. They all came together and with injuries so severe that many needed life-saving treatment at the exact same time. The inpatient wards swelled beyond capacity, yet we did not have the staff to manage this. Many of the team just kept working later and later each day, pushing past their limits. There was no other choice. Even between these events we were much busier than before with trauma victims. More skulls fractured open, more hands and feet blown off, more injuries bleeding inside chests and abdomens needing immediate intervention, more faces smashed in. Some cases were brought in already dead. Some were immediately palliative as our staff sat with the parents of children waiting for them to die peacefully. Others were the friends and family of our staff. Explaining to our translator that there is nothing we could do to save his uncle who was hit by a rocket, he understood: "Many of our family have already been killed. We know this is what happens." At a later bombing of a local village our new doctor lost three family members. He quickly moved his family the following day and then turned up for work again and I couldn't say to him, "take some days off, you need it". The line between staff and victim had long since been lost.

Today, Syrians are dying not only from bullets, bombs and missiles, but also from easily treatable and preventable illnesses. These are the silent casualties – people with chronic conditions like cancer and diabetes who can no longer get treatment following the collapse of the health system. They cannot be referred outside the country and so they are dying slowly. We are seeing evidence of hepatitis A generally, along with measles in children who have not been vaccinated in more than two years.

Although MSF initially focused on providing emergency and trauma care, we have now extended to include primary health care consultations, maternal care, polio and measles vaccination campaigns, mental health programmes, and donations of medications to treat communicable diseases such as typhoid and chronic illnesses. We are working with 450 team members on the ground in order to deliver these essential medical services. In areas where we cannot send our own teams because of insecurity or lack of access, in the past two years we have expanded our programme of supporting Syrian medical networks, hospitals and medical posts by providing drugs, medical equipment, and technical advice. We are now supporting 84 health structures. The majority of the clinics MSF supports are in opposition-controlled areas, but some are in government-controlled areas, or areas of conflict under mixed control. In many areas, people are too scared to cross front lines to access health care, and health care workers have been killed, arrested, tortured or threatened. Medical structures are relentlessly bombed and military bases have been established close to makeshift hospitals, putting these medical facilities at risk of being caught in the middle of fighting or being directly hit in an attack. The situation is so extreme that some doctors have told us they feel it is more dangerous for them to be caught carrying medical supplies than if they were caught carrying weapons.

Despite the challenges of medical supply throughout Syria, there is some level of capacity being sustained in government-controlled areas, and an underground movement of medical facilities operates in opposition areas. These structures are set up in incredible conditions – from kitchen tables to underground basements. However, this medical capacity is not provided outside the divides of the conflict and therefore both sides view health providers as targets. Field hospital are almost systematically bombed, health workers in government hospitals are threatened not to go to work and medical staff provide treatment to the wounded in secret. One of the latest examples of this was in early September when a field hospital in al Bab, northern Syria, was bombed by the Syrian air force, killing nine patients and two medical staff.

The challenges in responding to the humanitarian fallout of this brutal conflict are immense. There is an insufficient deployment of aid in Syria. For those providing aid across borders - such as Médecins Sans Frontières – it is impossible to have extensive geographic coverage. Aid is confined to a very small area close to the Turkish border and it is possible to address only a fraction of the needs. Since the beginning of the year, fewer than 20 UN and ICRC convoys have managed to cross the front lines. Only a large-scale cross-border supply operation can meet the needs that arise from the fighting, the widespread destruction, population displacement and collapse of public services. What we are seeing today is that even this very limited deployment of aid is being squeezed and is under constant threat. We need to see more humanitarian actors accepted to work in Syria by the Syrian government, a complete lifting of restrictions on where medical aid can be deployed and respect for the safety of aid actors to be shown by both the armed opposition and the Syrian army. To achieve this we need to see a diplomatic mobilisation similar to that we saw around the issue of chemical weapons