MSF
Barcelona
March 2015

Aleppo’s Reality:
Daily Life
under Barrel Bombs
Voices from
Eastern Aleppo
A Compilation of Testimonies Illustrating the Hardshipsof Daily Life in Eastern Aleppo under Barrel Bombings,
through the Eyes of Local Residents© MSF

‘‘Life for us has become unbearable, but wecannot afford to leave as I am fortunate
to still have a job in Aleppo. Those who canafford it have left to Turkey. Others are stuckin camps on the Syrian side or are seeking
refuge wherever they can just to get out of
Aleppo. Daily life is full of fear: you don’t know
who to trust, who you can talk to. Family life isbreaking down and couples fight. Few children
go to school and they have become restlessand scared. Crime and looting have soaredin Aleppo, which used to be a calm and safe
place. The security situation is unpredictableand bombardments can happen at any
moment. Life is unbearable.’’Mahmoud, resident of Al-Salame, Aleppo1

1		 Note that names in this document have been changed in order to protect the identityof those who provided testimonies to MSF.

Aleppo’s Reality: Daily Life under Barrel Bombs

Contents

4

Executive Summary

5

1
Background

6

2
Life under Barrel Bombings: a Climate of Fear

8

8
8
9

10

3 MSF

3
Medical and Health Consequencesof Prolonged Bombardment
3.1.
Casualties of Barrel Bombs
3.1.1.
Losing Family Members
3.1.2.
Losing a Limb
3.2.
Everyday Health Problems Facedby Eastern Aleppo Residents

11

3.3.
Born into a War Zone: Deliveries

11

3.4.
The Plight of Aleppo’s Medical Doctors

14

4
The Effect on Children

16

5
Family Tensions and the Weakening Social Fabric

18

6
Forced Displacement

19

Concluding Remarks

Aleppo’s Reality: Daily Life under Barrel Bombs

Executive
Summary“You could be sleeping. You could be walking to the shop. At any
time a bomb can happen,” says an MSF health worker in one of
the hospitals the organisation runs in northern Syria. This reports
aims at depicting the dreadful humanitarian situation in Aleppo cityand surrounding areas especially since mid-December 2013, when
the Syrian forces started a campaign of aerial bombardments anddropping of barrel bombs in this strategic area of the country.
Barrel bombs have caused thousands of fatal casualties andwounded and have had a devastating damage to infrastructureand homes. Dropped in densely populated areas, they create aclimate of fear due to their unpredictable and indiscriminate nature.
Many victims become permanently maimed. Losing a limb in Aleppo
city is particularly traumatic, both physically and psychologically,
since wheelchairs aren’t available and the context of war makes
it harder for them to adapt to a new life. Moreover, shortages
in medical equipment and poor levels of post-operative care havemeant that in many cases doctors carry out amputations when
under other circumstances the limb could have been preserved.
However, access to healthcare is now virtually impossible due to lackof supplies and qualified medical staff and medical services for the
residents of eastern Aleppo have diminished to alarming levels. Froman estimated 2,500 doctors working in Aleppo at the beginning of
the conflict, less than a hundred remain in the medical structures still
operating in the city. The rest have fled, become internally displacedor refugees, or have been kidnapped or killed.
The aerial bombardments have led to lack of electricity anddestruction of houses and infrastructure. People are now seeking new
ways of heating, and the widespread use of home-made combustibles
has caused a number of domestic accidents, such as burnt cases
among children. Treating burnt patients is very challenging in thecurrent scenario of war and lack of medical care in Aleppo.
Vaccination campaigns are also desperately needed, but it is
impossible to carry them out in eastern Aleppo: normal daily life has
stopped, people are running away, and markets, schools and any
place with presence of civilians are likely to be bombed.
MSF’s teams have also observed an increase of obstetricalcomplications due to exposure of pregnant women to stress aswell as lack of antenatal care for prevention and treatment ofcomplications such as preeclampsia which in turns increases risk ofpreterm delivery, miscarriage and small for gestational age newborns.
Premature babies need a special neo-natal care that it is hardly
available now in eastern Aleppo.

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Aleppo’s Reality: Daily Life under Barrel Bombs

Ghost neighbourhoods are the metaphor of violence anddisplacement. Out of the 97,000 Syrian refugees in Turkey’s border
town of Kilis, a 20% (19,400) arrived during the last six months.
The ones staying behind do not have the financial means to move,or they fear their houses will be looted.
The psychological dimension of the war is difficult to grasp, but
Aleppo, once the economic and vibrant hub of Syria and now almost
destroyed and deserted, is a living tale of the collective descent intochaos. Virtually every individual has a tragic story to tell because war
has affected family, friends and dear ones.

1
Background

Médecins sans Frontières (MSF) has been working to support
individuals and communities affected by the Syrian conflict since2011. What started as an uprising has grown in complexity, involving
now many actors, a high level of insecurity, and displacing millions ofpeople. Syria has become a human and humanitarian catastrophe
where meeting the life-saving and basic needs of the affected
population is challenged by the difficulties of keeping pace with therapidly evolving situation.
Since early 2012, MSF has focused its efforts on the north of Syria,
where levels of violence have been relatively and consistently high.
By supporting local field hospitals, MSF has been able to provide
essential primary healthcare for many communities unable to accessthe few remaining regular hospitals, as well as providing emergency
care and surgery for those men, women and children injured in theviolence, especially as a result of bombardments. MSF has also
been able to conduct specialised programmes such as measles
vaccinations for children and provision of humanitarian assistancesuch as water and sanitation services, and distribution of non-fooditems to internally displaced Syrians from Aleppo governorate.
Aleppo today is a city divided in two. Many families and friends are
separated across east and west. Between them lies the Bustan
al-Qasr crossing point, a dangerous area with frequent sniper firecausing high numbers of casualties. Mobility between the two sides isincreasingly difficult, and by today, restricted to special humanitariancases, under the supervision of Syrian Red Crescent. Many residents
are fleeing Aleppo and moving to wherever they can. To worsen thesituation, from mid- December 2013, Aleppo began to be heavily
bombarded with the use of barrel bombs. These types of bombs
cause devastating damage to infrastructure and homes, and theirtargeting or urbanised areas leads to high numbers of casualties
and creates a climate of fear due to their unpredictable andindiscriminate nature.
The presence of MSF in this northern part of Syria has allowed it
to gain a rare insight into the daily challenges faced by people in

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Aleppo’s Reality: Daily Life under Barrel Bombs

Aleppo under barrel bombs, in particular across the eastern partof Aleppo where people face increased difficulties. Their struggles,
their fears and thoughts are communicated to MSF through ourwork in the hospital network (be it in Syria or in Turkey). This
report aims to give a snapshot of daily life in eastern Aleppo
after months of intense barrel bombings, through testimonies ofresidents and health workers in Aleppo. It also highlights theplight of the medical staff working to provide healthcare to othersin such a challenging environment and the immense courage andprofessionalism they demonstrate in doing so.

2
Life under
Barrel Bombings:
a Climate of Fear

People today living in eastern Aleppo arescared and barrel bombings can be
unpredictable and widespread. In many
areas, daily life has all but stopped
functioning…

© MSF

Aleppo has much changed from the ancient and wondrous city thatonce aligned the famous Silk Road. The eastern part of Aleppo oftoday, after being ravaged by war for the last year and a half andunder relentless bombardment for the past months, is a city andprovince wracked by fear and uncertainty. Infrastructure, where
not destroyed, has severely deteriorated and the regular municipal
services do not function properly. In most parts of the city thegovernment no longer provides any services. In the east, the “free”
civil administration has taken on the responsibility to carry out
municipal services; however, with other priorities and a lack offunds, these services are often neglected and local communities andindividuals end up trying to take care of their own neighbourhoods.
Electricity is available intermittently, perhaps for an hour every day,leaving families in intensely cold temperatures during the wintermonths when the weather oscillates between 19° and -3°.2 Largeparts of eastern Aleppo city are reported to be destroyed by air
bombings, such as much of Hanano neighbourhood, and residents
no longer frequent markets or bus stations which could
be targets of shelling.
Many neighbourhoods have now been wholly or partially emptied,leaving an eerie feeling of neglect. Abandoned homes line thestreets, and thieves and looters are rife, pillaging houses and stealing
personal or valuable items that families have left behind fromtheir old lives.

2		 Accu.weather.com

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Aleppo’s Reality: Daily Life under Barrel Bombs

© MSF / Anna Surinyach“Aleppo never used to be like this. We didn’t have theft. We didn’t
have looting. Now all we have is uncertainty. We don’t know whoto trust and who we can speak to. We are scared to voice opinions
or say anything to anyone in case there will suddenly be a violent
retribution.” Ra’ed, hospital worker in al-Salameh, Aleppo

Barrel bombings in eastern Aleppo are so unpredictable andwidespread that they sow fear among people. It is extremely difficult
to take measures to protect your family and improve your safety,
which contributes to higher levels of psychological stress.

“You never know when a bomb can happen! This is the problem. You
could be at home having dinner. You could be sleeping. You could bewalking to the shop. At any time it might happen. Especially coming
to Turkey, for those who have to go to Turkey for work or to unite
family members, it is a very scary route as you don’t know who
you might meet and what might happen. You don’t know if you will
return home alive or see your family again.”Tareq, health worker in al-Salameh, Aleppo© MSF / Anna Surinyach

Another aspect of this constant threat of bombardment at any
moment, which has become a reality for many eastern Aleppo
families, is the concept of preparing oneself for any eventuality andliving every moment as if it were your last. Syrian refugees
in Turkey talked about how this uncertainty affected their lives
before they fled:“The funny thing is, we all had our bags packed… all the time! Justin case. Our suitcase was ready by the door at any moment with ourmost valued or sentimental possessions, in case we had to suddenly
flee. This constantly reminded us of the situation, like we were ina time capsule, not living the real world. All the women of Aleppo
started to sleep completely covered, with the Hijab etc., in case thebarrel bombs would hit them in the night and they would be caught,
dead, in their pyjamas! It sounds strange but these are things thatpeople were really worried about.” Miriam, Syrian refugee in Kilis, Turkey

The residents of eastern Aleppo talk much of the weather. The
reason for this, they explain, is because barrel bombings happen only
when skies are blue. “In Aleppo we now celebrate when it is a dark
and cloudy day”, said one refugee in Turkey. “Then we know we will
have some hours of respite before the next bombings start…”

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Aleppo’s Reality: Daily Life under Barrel Bombs

3
Medical and HealthConsequencesof Prolonged
Bombardment

Medical needs are not being adequately
addressed in eastern Aleppo. Casualties arehigh from barrel bombings, and in addition
people seeking regular medical treatment
cannot find it because of the dire shortage of
specialised resources and equipment.
3.1. Casualties of Barrel Bombs© MSF / Anna Surinyach

3.1.1. Losing Family Members
The war in Aleppo, and in particular the three month barrel-bombing
campaign across eastern Aleppo, has caused high amounts of fatal
casualties and, unfortunately, there is likely to no longer be a family left
in Aleppo that does not have a family member or an acquaintance thathas been killed in this manner. Reports from 10 hospitals supported
by MSF in Aleppo city illustrate the numbers of casualties caused by
the violence. In just one of those hospitals, for example, three deaths
and 40 injuries directly provoked by barrel bombs attacks wererecorded during the month of January 2015, as a consequence of the
3 barrel bombs attacks/day registered in Aleppo City.

“One day when we were working at the hospital [in eastern Aleppo],
it was a day of a high number of barrel bombings. It was like thecity was in chaos and lots of people were being brought to us, deadand alive. I remember when two bodies were brought in, of an old
man and his small grandson; they both had the same name.
They must have been together when the bomb hit. The family was
searching for them in all the hospitals of Aleppo but couldn’t findthem. Their neighbours had also been bombed so there was no one
to ask about the whereabouts of these two. Finally they came andthe bodies were identified. It was just one case, but still. We all
felt so sad.” Hospital staff member in eastern Aleppo

After a barrel bombing, the damage caused on a family house is often
so severe that body parts can be flung all over the vicinity. The surviving
neighbours and family members go to help retrieve the body parts
from damaged buildings, put them in bags and bury them according
to Islamic principles. Syrian refugees were telling MSF that after thisroutine of body part collection, a period of a kind of hysteria begins,
where people temporarily feel extremely overwhelmed and break down.
Burying the dead, however, is not always possible. Besides those who
die, there are thousands who are unaccounted for. Most families haverelatives who have disappeared – everyone seems to be searching forsomeone. Families do not know if they are dead, arrested or fled the

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Aleppo’s Reality: Daily Life under Barrel Bombs

country. But hospitals in Syria have many bodies in their morgues thatlie unidentified until they finally have to be buried in mass graves tomake space for more bodies.

3.1.2. Losing a Limb
Another serious consequence of barrel bombs is the fact that many
victims become permanently maimed, such as losing a limb which canbe psychologically as well as physically traumatic.
© MSF / Anna Surinyach

Shortages in medical equipment and poor levels of post-operative
care have meant that in many cases doctors carry out amputations
when under other circumstances the limb could have been preserved.
It is almost impossible to obtain a wheelchair in Aleppo, but evenmore difficult to move with it in through damaged neighbourhoods
and ruined houses. Prosthetic limbs and rehabilitation are also hardly
accessible. This makes the amputee suffer an even greater disability
and live with much reduced mobility in a city where people run when
they hear the noise of planes or helicopters.
Some persons bring blown off limbs with the injured with the hopethat it could be again functional, but due to the lack of means it
becomes in most cases impossible.
One amputee victim of a barrel bomb spoke to MSF while
recuperating in a hospital in Kilis, Turkey:“I left my work around 1 pm and was walking near the Haluania
roundabout in Aleppo when suddenly a tank bomb hit the middle of
the road. I was hit badly and immediately after the explosion I could
not feel my leg. A group of people carried me to a car and took me
to Al Daqaq hospital, which was only 5 minutes away. By the time I
had reached the hospital I had lost consciousness. The hospital staff
tried to contact my family, but could not reach anyone at that time. I
was taken to the operational theatre and when I woke up after 4hours of surgery, my right leg was amputated. The left leg was full ofrods and plates in order to keep it rigid. During three days I wasrecovering and then I was sent to the hospital in Al-Salameh. The
doctors there were very good with me and cleaned my wounds
regularly to prevent infection. When the doctor told me each day that
I was healing and getting better it helped to lift my mood. I spent
1.5 months in the hospital until the day when we were forced toevacuate to Kilis, Turkey. Now I am here continuing to recover. I will
get a wheelchair and prosthesis to support me. Yesterday my father
brought me a meal that had been prepared by my wife in Aleppo. I
look forward to going home and seeing her and our 3-month- old son
again.” Khaled, 29 years, Kilis hospital, Turkey

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A 15 year-old boy, Mahmoud, was met by psychologists working ina mental health program supported by MSF in Kilis. A psychologist
described Mahmoud´s story:© MSF / Anna Surinyach“I met Mahmoud only recently, in Kilis hospital and felt completely
overwhelmed. He is a boy of 15, who was playing football withhis brother near their house in Aleppo when a rocket fell right where
they were playing. Mahmoud lost consciousness and was brought
to a hospital. When he woke up he realised that both his legs had
been amputated, and that his life would, from that day on, never be
the same. I met Mahmoud one month after the incident, and hecame up to me smiling and doing tricks in his wheelchair. He waslooking forward to recuperating so that he could get prosthetic limbs
put on and could walk again. ” Psychologist, mental health project, Kilis, Turkey

3.2. Everyday Health Problems Facedby Eastern Aleppo’s Residents
Prior to the conflict, Aleppo had a functional health system thatworked in preventing diseases and made primary, secondary andtertiary health care available for the population. TB, Cancer, andmany other chronic diseases were treated. Even during much of
the Syrian war many of these patients managed to continue theirtreatment. However, since the increased levels of barrel bombings andinsecurity in Aleppo started in December 2013, access to essential
treatment has now become almost impossible either due to lack ofsupplies and qualified medical staff or because of the high security
risks faced when trying to reach a health facility. As an example, due
to the fact that many health facilities in the eastern part of Aleppo
have closed down during the war, many patients such as dialysis
patients needing insulin had to cross to the west to access private or
public hospitals there. The crossing is extremely dangerous and risky.
There is thus an increasing number of preventable deaths.
Other kinds of medical problems have emerged as a consequenceof the bombings. The lack of electricity, destruction of houses andmany windows being broken have pushed the population to seek
new ways of heating. The increasingly widespread use of low quality,
home-made combustibles has led to a sharp increase in the numberof domestic accidents, such as burn cases among children. In theabsence of consistent quality medical care, adequate materials andtrained staff, treating burn patients can be complex, lengthy, painful
and traumatic for patients.
Regular procedures in eastern Aleppo have become complicated. Cold
winters in Syria produce an increase in respiratory infections that,
under normal circumstances, can be treated. However, the current
situation in Aleppo means that field hospitals serving the eastern

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Aleppo’s Reality: Daily Life under Barrel Bombs

areas prioritise surgery and acute medical needs. As a result, lackof treatment for such respiratory conditions and others can increase
under-5 mortality rates.
The fact that normal daily life in eastern Aleppo has all but stopped
since the heavy bombardment started, due to the displacement of
populations and the destruction of market places, schools, bus stops
and other places of civilian gathering, makes it difficult to conduct
health campaigns, such as much-needed vaccinations3. It is also
challenging in such circumstances to stop an outbreak from occurringand spreading.

3.3. Born into a War Zone: Deliveries
MSF’s teams have also observed an increase of obstetricalcomplications due to exposure of pregnant women to stress aswell as lack of antenatal care for prevention and treatment ofcomplications such as preeclampsia which in turns increases risk ofpreterm delivery, miscarriage and small for gestational age newborns.
The premature babies need a special neo-natal care that it is hardly
available now in eastern Aleppo. Even very basic support is limited
and many of the families have to seek care for the new-born inneighbouring countries, again forcing families to separate.
Logistical problems such as electric power outages and lack of spareparts to fix electric generators can also cause problems, such as thedeaths of three premature babies in one hospital.
In addition, the shortage of food, the precarious shelter, the almost
inexistent EPI, the poor nutritional status of the mothers and thehabit of using baby formula –now very expensive– increases thevulnerability of the under five kids. In the last years Aleppo has
witnessed outbreaks of communicable diseases such as leishmania,
measles, scabies, etc.

3.4. The Plight of Aleppo’s Medical Doctors
Medical services for the residents of eastern Aleppo have severely
reduced since the beginning of the conflict, which makes it muchharder to address the medical and health needs described above.
From an estimated 2,500 doctors treating all kinds of medical

3		 In spite of huge efforts of MSF and a number of volunteers form local organizations,the measles vaccination campaign in eastern part of Aleppo city in April-May 2013
ended up a very low coverage.

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Aleppo’s Reality: Daily Life under Barrel Bombs

services, the hospitals still operating in Aleppo count with 97
doctors in theirs services. The rest have fled, become internallydisplaced or refugees, or have been kidnapped or killed. As an
illustration of this phenomenon, in the whole of eastern Aleppo there
is no longer any neurosurgeon, nor ICU doctor. Hospitals in Sakhour,
Sha’ar, Shukari have been repeatedly hit by barrels bombs. First
Aid Points have been affected by shelling, closed or obliged to movein Al America, Al Ansari, Bustan Al Qasar districts. The paediatrichospital that was in Masaken Hanano has closed as a result of thebombing. These issues, coupled with the low number of regular
and ICU beds and incubators available, make it impossible torespond to the current needs of the population, and many patientsare going to Turkey to seek medical care.
Because of the lack of electricity at night and the unspoken curfew
adhered to in parts of eastern Aleppo, residents cannot drive at nightwith their lights on, for fear of being targeted, and patients often
have to wait until morning to be taken to hospital. In fact, medical
facilities and staff have been widely targeted and patients andcaretakers are afraid to stay in hospitals for any length of time. The
lack of beds, staff and the encompassing fear make post-operative
care even more difficult and trigger early discharge of patients
without being able to provide appropriate patient follow up. Whatshould be treatable complications are in fact contributing
to an increasing death toll.
Doctors in MSF-supported hospitals and other medical centres
are working around the clock to deal with the effects of Aleppo’s
barrel bombings, as well as trying to provide regular medical care
to sick patients. A number of volunteers without any medical
background have stepped up to help fill the gap4, but qualified
resources are desperately needed. One doctor in a hospital supported
by MSF 5km northwest of Aleppo recently wrote to MSF explaining
their situation:

4		 As an example, a number of non-medical volunteers participated in the Measles
Vaccination Campaign in Aleppo city held by MSF in April-May 2013, without whichit could not have been completed.

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Aleppo’s Reality: Daily Life under Barrel Bombs

© MSF / Anna Surinyach“Our situation is increasingly difficult these days because of thebombings. Most doctors and nurses have left now and we are few
people working under stress. We are currently a skeleton structureof staff that never sleeps. We just came out of the theatres. We areabsolutely exhausted, after having performed 100 operations andtreated 650 injuries in 2 months. It is hard but we persevere, withall the help we can get. We appreciate the work MSF is doing and it
helps close a huge gap we have, especially in pain relief
and anaesthetics, which allow us to do all the operations we do.”Doctor in local field hospital, Aleppo© MSF / Anna Surinyach

Doctors and medical and paramedical workers in eastern Aleppo
have to live through the same stressful situations as the rest of the
population, as well as working in precarious and dangerous conditionsin underground or makeshift field hospitals with much fewer
resources than they require. Many are working as surgeons despite
not having the proper training for conducting surgery and receive
large influxes of wounded people at the same time. Medical staff issometimes performing operations for 24 hours without any sleep.
They spend long periods away from their family and have to work
worrying about whether their family will be safe as well as whether abomb will fall on the hospital where they work. Unfortunately, medical
staff in Syria has been directly targeted during the war, in a blatantviolation of international humanitarian law, which obligates parties tothe conflict to protect the medical mission.

“We had a case recently that was devastating. After a period ofsevere bombardment, an influx of patients arrived to the hospital.
An entire family was brought in - they had been attempting to flee
to safety in Turkey. Two of the children were immediately killed in
the bombing. Out of the rest of the children, one of the sons, Nadim,
a boy of 12 years, had his leg amputated. His 9-month old baby
brother Amjad had both of his feet amputated. The mother had abroken leg. But the worst of all was when the other brother, 4 years
old, waved goodbye to his mother as he was taken into the operating
theatre to amputate the lower half of his body. These are awfulstories to witness, but it is made much harder when you feel you
cannot treat them properly because you lack equipment
and doctors. ” Doctor in Al Salameh hospital

Ambulances have started carrying two or three patients at one
time, which was previously inconceivable but now is imperative due
to circumstances. Ambulances, however, have been also destroyed in
the war, which makes many patients afraid to take them. As a result,inconspicuous mini-vans or normal cars are used to transport patients
despite not being equipped with the required medical equipment andhaving to cross dangerous checkpoints.

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Drug supply is extremely challenging for doctors, and as a consequence
many patients have to undergo complicated surgery withoutanaesthetic or accompanying antibiotics.

4
The Effecton Children

War has had a devastating effect on children
in Syria. Disruption of schooling, state ofinsecurity and loss of family members areamong the factors contributing to increasing
psychological stress among children
in eastern Aleppo.
Children are one of the most affected populations during a time ofwar. Children under 5 years old are particularly and dangerously
vulnerable to the impact of the deterioration in basic living conditions.
Moreover, the shortage of food or certain types of food can greatly
affect their normal growth patterns. The lack of many of the usual
preventive activities, such as routine vaccinations, can weaken themwhen in a hostile environment such as armed conflict.
Syrian mothers have not been prepared for these food shortages,
inability to vaccinate their children and the increasing necessity togive birth at home without assistance. Accessing health services has
become dangerous and services themselves have become more hard
to come by.
The re- emergence of deadly childhood communicable diseases ina country that was recently free of them is a distressing exampleof how war can kill not only with bullets but also through thedestruction of the health system. Whereas Syria was reported ashaving relatively good vaccination coverage prior to the war5, during
the last 3 years the vaccinations have been significantly disrupted
due to lack of supplies and staff to implement the programmes.
This has led, in certain areas, to very low levels of coverage where
just one case can prompt a much larger outbreak. MSF has beenaddressing this problem, within available means and despite security
constraints, through measles and polio vaccination campaigns forchildren in northern Syria.

5		 According to the World Health Organisation.

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© MSFIn rural Aleppo, many children are still able to attend schools, albeit
in sometimes rudimentary conditions. Many qualified teachers havefled, and as a result schooling is often carried out by local volunteers.
Most schools have been taken over for use by displaced persons,military bases or hospitals, and so this informal teaching is conductedin whatever small and safe spaces can be found. As for urban areas,in many areas of eastern Aleppo city, the children are no longer goingto school. Many schools have long been closed due to the insecurity
for both teaching staff and children, lack of funds and high numbersof displacement from Aleppo.

© MSF“Most schools have closed because insecurity is too high and people
are too scared to send their children to school, not knowing whatmight happen to them. But despite the whole education system being
on hold, peoples’ resilience comes out. You see instances where people
invent ways to keep the children occupied, local community councils
have been established to provide ad hoc services, and the “FreeCouncil” of Aleppo also organises some activities. There are attempts
here and there… however, overall education has been pretty muchhalted.” Staff member, eastern Aleppo hospital
Syrian children’s drawings in Kilis

It is observed that children are becoming more aggressive and get
into fights. A psychologist working with Syrian refugee children in
Turkey spoke of the effects that the bombing of Aleppo and the war
as a whole have had on its children.

“We see all types of children. Some are more balanced than others,
but it is obvious the war has affected them all in some way or other.
Those children who stayed in Syria much longer before becoming
refugees witnessed a lot and managed to develop some coping
mechanisms to deal with the trauma. But they saw a lot of deathand destruction, and seemed to “normalise it” which is not especiallyhealthy either. Seeing body parts became a regular occurrence. They
were bored and traumatised all at once. Here in Kilis we still see
many effects on children. Kids up to 15 years are wetting the bed.
They have nightmares and cannot sleep. Many feel a lot of anxiety
and feel insecure. Their schooling has been interrupted and they havelost touch with their friends and communities. Those children who
had one of their parents killed in the bombings tend to display violent
and angry behavioural patterns more than others.”
Abu Omar, a psychologist in a mental health programme supported by MSF in Kilis, Turkey

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Aleppo’s Reality: Daily Life under Barrel Bombs

© MSF

Children are also at risk of being caught in the bombardment if they goout of the house. When there are heavy periods of bombardment they
are forced to stay indoors and get very little chance to play outside,something that is an important activity for the healthy development ofchildren.
Often children become victims of bombings. In Kilis, Turkey,
psychologists and community health workers in a mental healthprogramme supported by MSF visit children who have been injured.
The children can be distracted with games and toys, but theirdiscourse often returns to the war. Some of them attend classes but
are quite despondent and lack energy levels. The drawings they wereasked by psychologists to draw of their family ended up being picturesof barrel bombs on their houses (see some of the pictures below). They
play games related to the war and talk of fighting. Their families talkincessantly of the war and it seems that the war context is constantly
present – they never manage to escape it.

Syrian children’s drawings in Kilis“One child we have been working with, Muhammed, is 6 years old.
One night he was woken by the sound of explosions nearby, and his
family decided that they could no longer live in this insecuresituation: they had to flee. They took their most urgent belongings
and made their way to Kilis in Turkey. Muhammed, however, still has
not recovered from the events he lived in Syria, often thinking andtalking of planes, of bombs, of attacks on mosques, of dead victims.
He has frequent nightmares and is constantly thinking about thewar. He often feels scared and the smallest sounds frighten him. He
feels angry at the people who fight which made him leave his homeand school. He is only 6 and he has had to deal with so much.”
Community Health Worker, Kilis, Turkey

5
Family tensions
and the weakeningsocial fabric

16 MSF

Family separation, deaths, unemployment,
political differences and forced displacement
have all led to break-ups among formerly tightknit families and communities…
One of the collateral damages of the war, and an aspect rarelycommented on in the media and in analyses on Syria, is the break-up
of social and family relations. Relations are stressed in the Aleppo
context for various reasons, relating to political differences, economic
tensions, changing behavioural patterns, and physical separation
because of displacement or death.

Aleppo’s Reality: Daily Life under Barrel Bombs

Aleppo residents complain that living costs have increased, as aresult of the general scarcity of resources during the war. Most
products – even basic staples such as bread for example – have been
scarce at times.

“Things were especially difficult in western Aleppo when it was
besieged by the opposition and most roads were closed – there wasonly one way to get in and out and it was quite dangerous [becauseof snipers]. But 1kg of tomatoes for 100 SP in the rebel area would
cost 400 SP in the government area! A gas cylinder costing 3000
SP in the rebel area would cost us 7000 in the government area!
Same for bread since no flour could be brought in. So as you canimagine a whole economy grew around sending people to the otherside to get cheaper goods. But sending someone was dangerous andof course cost money too, so in the end you paid practically the same
expensive price!” Psychologist in mental health programme, Kilis, Turkey

People who are forced to flee lose their homes often have many
belongings looted. They go to Turkey or to rent another apartment in
Aleppo countryside, which is a further financial stress. Many people
have lost their jobs. Some people work in transporting goods to andfrom the Turkish border, under stressful and insecure conditions. Those
who cross to Turkey can usually find menial jobs, but are often severely
underpaid (5 – 15 Turkish Lira a day, or about US$ 7), especiallybecause of the constraints of not being able to speak Turkish.
All these issues, coupled with increasingly frustrated children who don’t
go to school, deaths in the family, and constant bombardment canplace enormous stress on the family life.

“I don’t know how to fix my family. I feel it is broken. I work all day
for my family and return home to find my wife has lost her temper
again with our children and is being violent with them. If I try andtalk to her she doesn’t listen. I don’t have much control any more,
and as the father of the family I feel I am not living up to myresponsibilities.” Staff member in al-Salameh hospital, Aleppo

The psychologists talking to Syrian refugees who arrive in Turkey notesimilar strains. Relationships become cold between married couples
as they face stressful situations. Family members often stop talking
to each other or, worse, fight each other because they are on opposite
ends of the political spectrum. Parents find it increasingly difficult
to deal with uncontrollable children who are increasingly nervous
and aggressive. And fathers feel frustrated that they cannot provide
economic means for their family. Increasing levels of violence are being
reported between men and their wives, and between parents and theirchildren, than was previously present in Syrian families.

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6
ForcedDisplacement

The insecurity and the unliveable realityof Aleppo today, as well as the need to seek
medical services or work opportunities, haspushed many residents of eastern Aleppo toflee to the countryside or towards Turkey…

© MSF

It is out of the scope of MSF’s capacity to record numbers of people
forced to leave their homes in Aleppo; however, MSF staff have been
observing large movements of people out of the city during the few
months of intense barrel bombings. Those people who have decided
to stay in Aleppo do so mostly because they do not have the financial
means to move. Others stay in order to protect their homes fromlooters. But many more have fled from the insecurity and thestruggles of daily life such as those described in this report.
It appears that some of Aleppo’s neighbourhoods that were moreheavily bombed (e.g. Hanano, Haydariya) are emptying at a faster
rate, with the majority of residents having left. In otherneighbourhoods (e.g. Sakhour, al Fardous), a substantial number ofresidents have also left, either to other areas or to Turkey. Someneighbourhoods, such as Maysar, Jazmati, al- Marjeh and
Masaraniyeh, and al-Ashrafiyya are practically deserted, with shops
closed and no activity at all. The areas of Bastan al-Basha, the old
Aleppo citadel and “7 Bahrat” neighbourhood are like ghost towns.
The most important ancient marketplace of Aleppo has been
destroyed.
A resident in Aleppo described one such neighbourhood, Jazmati:“Jazmati is a neighbourhood in the south eastern part of Aleppo, near
the airport. In late January 2014 the security situation there started
to deteriorate and there was an indescribable terror unleashed upon
its residents. It was an incessant bombardment by helicopters andbarrel bombs, which made every day unbearable and scary. This
continued until mid- February. During that period, the neighbourhood
population of 2000 families was reduced to just 60 families, andpeople so far have been too scared to return. The possibility of thearea being stormed by troops from the east is too high, especiallyas they are using heavy weapons. The strange thing is, when you
go there, that when it starts to get dark you don’t see any humanbeings any more in the streets. Only cats and dogs, and also rats
wandering in and out of the ruins. At that time of day even thearmed combatants disappear.”

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Aleppo’s Reality: Daily Life under Barrel Bombs

Some residents have been fleeing to more western parts of Aleppo
or to other areas of rural Aleppo where the shelling is less severe
and the situation is ore normalised. They stay with friends or familyor rent out empty houses in those areas. Larger numbers have beenheading up to the border and stay at the makeshift (“transit”)
camps for IDPs such as “Maaber el-Salame” and “Tlel el- Sham”,
where the situation is relatively stable. The largest number however,are those that have managed to get some money together and headout of the country entirely, going to Turkey to stay in the refugee
camps or try and find a job, along with the hordes of other Syrian
refugees. Out of 97.000 Syrian refugees in Turkey’s border town
Kilis, a 20% (19.400) has arrived during the last 6 months.
However, they are not entitled to stay in camps. They stay outside
camps, just like the other estimated 40.600 unregistered who werealready living there.
Those IDPs without ID documents, however, cannot legally cross theborder, placing a further obstacle for many wanting to flee.

Concluding
Remarks

The Aleppo of today, roughly divided between east and west, is ashell of its former charming self. The ancient Aleppo citadel and souq
are now abandoned and lie in the dangerous no man’s land which
represents the front line between fighting sides.
Everyday life in Aleppo is not simple any more, and small things havebecome a challenge. Many children no longer go to school, shops areclosed or have shortages of food items, prices have risen sharply
due to the scarcity and many people have lost their jobs. Looting
and stealing is increasingly common as people ravage houses whose
residents have fled to scavenge whatever they can.
The campaign of barrel bombings on eastern Aleppo since December
2013 has had a devastating impact on the population and thecity’s infrastructure. Too many people have lost family members
or acquaintances and death has become a frequent occurrencein Aleppo. Too many others have been maimed by bombings, andamputees are increasingly common. Many of the victims are womenand children.
One of the worst casualties of the war has been the health system
and medical structures. Victims of the barrel bombs, but alsopatients seeking regular health care or routine treatment for chronic
diseases are finding it increasingly difficult to access health facilities
and receive care. There are too few doctors left in Aleppo, let alone
specialised expertise, medical equipment and drugs. Medical staff
that has chosen to remain are forced work under difficult, stressful
and precarious conditions. The doctors in Aleppo supported by MSF

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work hard to treat patients, but they themselves are extremely tired
and desperately need reinforcement. Like the rest of the population,
they are under constant risk of bombing.
There is no respite, however, from the barrel bombs. These bombs,
by design, are destined for effective targeting of urbanised areasin which there is a high concentration of civilians. Because of thewidespread destruction caused by these types of bombs and theirunpredictable nature, people no longer feel safe inside buildings.
Instead, many are moving either to the countryside or to camps in
the north of Syria, moving to Turkey if they have the means. People
are terrified of eastern Aleppo becoming an enclave, and overall
there is a high climate of fear.
The people of Aleppo are desperately in need of medical andhumanitarian assistance. Wherever it can, MSF is supporting
the medical structures that are providing medical services to thecommunities of Aleppo, despite the challenging environment. However,more attention on Aleppo and more aid to its surviving residents –especially those in the more neglected eastern neighbourhoods - areimperative. As the city becomes increasingly unliveable and like awarzone, MSF stresses the need to not forget the humanitarianneeds of the civilian population that still remains.

MSF calls for:• Urgent attention to the humanitarian situation of residents ofeastern Aleppo and the plight of medical doctors striving to provide
medical care;• Protection of civilians and the medical mission in Syria;• A humanitarian space which can guarantee access for humanitarianassistance and population movement.

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www.msf.org