As thousands of civilians remain trapped in Syria's Yarmouk refugee camp, an outbreak of potentially fatal typhoid has been reported, amid a wider health care crisis. While the U.N. subtly declassified the area – a Palestinian refugee camp south of Damascus which used to be home to over 200,000 people – as a besieged area in June, thousands of civilians remain inside the camp, which ISIS entered in March, and has largely occupied since. No aid has entered the camp for the last two months, according to Wesam Sabaaneh, the director of the Jafra Foundation, which was until recently one of the few local NGOs still working in the camp. All major aid organizations, and the U.N., have stopped working inside Yarmouk. Before June, small amounts of aid were being distributed to areas just outside of the camp, in Yalda and Babila, for example, and civilians were very occasionally allowed out of the camp to collect a food basket. But since ISIS took over around 70 percent of the camp, restrictions have become even tighter, and in June the Syrian government rescinded aid access even to these areas outside of the camp, according to a U.N. source. "The aid was coming from the neighboring areas. For example, we were in Babila, and the civilians from Yarmouk can come and get a food basket. But for 60 days, nothing has entered, even to the neighboring areas," Sabaaneh says. Now, with no food or medicine entering the camp, typhoid, malnutrition and hepatitis are widespread, he adds. "It is the biggest outbreak of typhoid we have seen thus far," he says. "And that's because of the water, and because of malnutrition – the body is unable to fight off infections. And because of hygiene issues, there are no hygiene materials and no water." For over a year, there has been no drinkable water delivered into the camp, so residents extract water from ad hoc wells, run on expensive black-market diesel. Typhoid is a highly contagious bacterial infection, most common in areas with poor hygiene and reduced access to clean water. Dr. Akihiro Seita, director of UNRWA's health program, said that the agency was desperate to enter the area to confirm the reports of the outbreak of typhoid, and of hepatitis A, a viral liver infection also caused by poor water supplies. "We are very much concerned about the reports of typhoid and hepatitis," Dr. Seita says. "They are all water-borne diseases, and the water conditions are not ideal at all." "We really want to go in and check, as we don't know the extent." But, he added, the biggest health concern was not a particular medical problem, but the "entire environment. The levels of malnutrition show that the food supply is not secure. We need to provide care and treatment, antibiotics and high-energy supplements." The camp's one hospital, the Palestine Hospital, is no longer operational, Sabaaneh says. "It has no equipment, doctors, medicine or electricity," he says, adding that one small clinic is operational in Yalda, but Yarmouk residents have not been allowed to access it now for months. The nurses who remain in the camp have received but rudimentary training from the Free Syrian Army, Sabaaneh says. "If someone is shot in the arm," gesturing to his forearm, "they just cut it off here at the shoulder." "There is no medicine left in the camp, everything we use is alternative medicine," he adds. Even the bandages, he said, are made from tissue paper. Sabaaneh – who is from Yarmouk – says the declassification of the camp as besieged, a decision made by the U.N. Secretary-General upon recommendation of the body's Office for the Coordination for Humanitarian Affairs, is inaccurate but makes little if any difference to day-to-day life in the camp. "Even when it was classified as besieged, it didn't change anything, only more concentration from the media and the U.N. community but without any real effects on the ground, so unfortunately it doesn't matter." The declassification does, however, benefit the government in Damascus, he says, as all along they have maintained that the area was not besieged. At OCHA, the agency's Undersecretary-General for Humanitarian Affairs Stephen O'Brien defended the decision at a media briefing in late July at the U.N. "The question of classification is quite strictly applied: If the central population of a city or village is described as besieged then it is because no aid can get in. ‘Besieged' means that nothing is going in or coming out," he said. In contrast to Sabaaneh's reports, he added that some people had been allowed out of the camp to collect aid from the outskirts in the last two months. "What has been the case in June and July is that there is access to the three neighboring areas of Yalda, Babila and Beit Sahm, and there is some movement of the people in Yarmouk between their area and those three areas. Some people are staying in those three areas, others are collecting life-saving commodities and medical supplies and taking them back into Yarmouk." At UNRWA, the agency's spokesperson Christopher Gunness says that as soon as it again receives authority to conduct missions into the areas around Yarmouk, it is ready to do so, and that hopefully typhoid medicine will be able to be delivered as of next week. Speaking to The Daily Star, he says, "We are extremely concerned about Yarmouk to which we have had no access since March 28. We have had no access to the adjacent areas since the first week of June. "We have been given no explanation as to why our access to Yalda, Babila and Beit Sahm was rescinded, but we have received indications that limited missions – medical only, such as our response to reported cases of typhoid – may be permitted from next week," Gunness says. "UNRWA stands ready and prepared to mount a significant humanitarian response [in the areas around Yarmouk] on an indefinite basis ... Given clearance, we're ready to go in 24 hours or less." Until then, local groups such as the Jafra Foundation continue to work outside the camp to provide assistance to the refugees from Yarmouk, providing education, waste management and water trucking to the best of their abilities. "The situation is very bad. Whatever we do, we are a local NGO and we cannot do a lot. But at least we are doing what the U.N. is not doing," Sabaaneh says. "We cannot cover everything, but we try. It's also very risky work, and we are staffed by volunteers. There is shelling, kidnappings. A few days ago, ISIS killed one of our volunteers. They thought he was working with the regime."
