AMMAN: The former resort town of Madaya, which captured the world’s attention earlier this year as starvation killed dozens of residents despite a truce with the regime, faces a new danger as malnutrition cases multiply and at least four people have died in the last two weeks from its complications.

While death by starvation is now less likely for the 40,000 civilians trapped inside the encircled town 40km northwest of Damascus after several high-profile aid deliveries, the new and growing threat of malnutrition is replacing it.

Two doctors and several activists inside Madaya tell Syria Direct that the aid convoys, including one in October, three in January and one in February, delivered food with high levels of carbohydrates and low amounts of protein, a combination that given to starving people can induce bloating, and kidney and liver failure.

“The humanitarian aid that entered [in January] had little protein, which led to liver and kidney function failing, as well as the failure to absorb food through the intestines,” Mohammed Yusuf, head of the Medical Society in Madaya, told Syria Direct Tuesday.

The result? “Retention of fluids in the body” leading to bloating in the face, ankles, feet and stomach, said Yusuf. [For pictures documenting the swelling, see the Medical Society in Madaya's Facebook page here].

While the humanitarian aid that arrived throughout January and February contained protein in the form of lentils, beans, and chickpeas, Yusuf said that “what we lack is animal protein,” and added that the food in the aid parcels “can cause bloating.”

Yusuf cautioned that the problem is “not just a lack of protein [among Madaya residents], but also a lack of fluids and vitamins.”

 
A Madaya child last month. Photo courtesy of Dr. Mohammed Yusuf.

More than 2,000 of Madaya’s remaining residents have sought medical help for bloating due to malnutrition beginning the week after United Nations humanitarian caravans carrying aid first arrived in January, said Yusuf. An estimated 112 of those patients have been diagnosed with Kwashiorkor, an extreme form of potentially fatal malnutrition characterized by swelling in the body.

“It's a huge number, more than you could imagine, and all residents are at risk, including medical staff,” Mohammed Darwish, doctor at the field hospital from Madaya told Syria Direct Tuesday.

Four Madaya residents have died of complications from malnutrition-related bloating over the past two weeks, Hussam Madaya, a member of the United Aid Society, responsible for distributing humanitarian deliveries in the city, told Syria Direct Tuesday.

In a statement to Syria Direct Wednesday, UNICEF spokesman Kieran Dwyer said that UNICEF teams “delivered nutrition items sufficient to treat 920 cases of severe acute malnutrition, as well as other supplies for prevention of micronutrient and acute malnutrition among children and mothers,” during the January and February aid deliveries.

UNICEF wanted to deliver nutrition kits to treat 200 severe acute malnutrition cases with medical complications, “but these kits were not approved by the government and were not delivered,” added Dwyer.

The WHO also provided in February “supplies (life-saving medical kits) to treat 100 cases of complicated severe acute malnutrition with health complications,” Tarik Jasarevic, spokesman for the WHO, told Syria Direct Tuesday.

Madaya entered into a truce agreement with the regime in September 2015 that stipulated the entrance of aid to regime-controlled Kafariya and al-Fuaa in Syria’s north in exchange for the regime doing the same in rebel-held Zabadani and Madaya, reported Syria Direct December 8.

 
A still taken from a video recently filmed in Madaya of the effects of malnutrition. Photo courtesy of Dr. Mohammed Yusuf.

Despite the truce, Madaya remains under a blockade imposed by regime forces and its ally Hezbollah that began last July during a battle for control of neighboring rebel-held Zabadani, a gateway to key smuggling routes into Lebanon across the Qalamoun mountains.

The ongoing blockade of Madaya is punitive: Attempting to leave the town or smuggle anything or anyone in or out can be deadly.

At least 30 civilians have been killed by landmines or snipers trying to pass through Madaya's security cordon, according to a January report by the Syrian American Medical Society.

“Government and allied Hezbollah forces have put landmines around Madaya, making it incredibly dangerous and difficult for civilians to leave or for anyone to smuggle food into the towns,” the report concluded.

“Madaya…has been inaccessible…despite numerous requests for access,” the UN Office for the Coordination of Humanitarian Affairs said in a statement in January.

The first delivery of aid into Madaya after the truce was signed took place on October 18, when the UN distributed food that included high-energy biscuits. But nearly half of the biscuits were expired and gave hundreds of residents, mainly children, food poisoning, reported Syria Direct at the time.

By the time those rotted biscuits arrived, Madaya residents were getting by on foliage such as cooked leaves from berry bushes and unripe mangoes from nearby orchards that have not been burned down by the regime, Husam Madaya, the member of the United Aid Society who also serves on the Local Coordination Council in Madaya, the town’s local administrative body, told Syria Direct in December. 

“The residents here live on one meal a day at best, while many other families go days without food,” said Husam Madaya at the time. “The only food available is rice and bulgur, and there is no flour or any vegetables.”

Farms and orchards constitute the Zabadani plain, located in the valley west of Madaya.

The world turned its attention to Madaya in late December, when images of starved civilians began circulating widely and the international media descended upon the town. After humanitarian aid deliveries coordinated by the UN, Red Crescent and Red Cross entered in January, and again in February, coverage of Madaya largely dried up.

But the starvation problem, and the consequences of uneven nutrition, persisted. Doctors inside Madaya say they have few options to treat suffering patients.

Injections of albumin, a naturally occurring transport protein found in the body, “are not available” due to the encirclement, said Darwish.

Medical experts cite specific protocols to treat malnutrition, with extreme cases requiring hospitalization.

“Severe acute malnutrition is a disease and it has to be treated with specific drugs (therapeutic food at least 500 calories, three times per day) and be followed very closely,” Silvia Dallatomasina, medical coordinator at Médecins sans Frontières (MSF), told Syria Direct on Tuesday.

“If a malnourished patient is wrongly treated, with normal food not balanced in term of calories and micro-nutrients, they can develop edema (swelling), and also kidney or liver failure,” said Dallatomasina.

Gemma Dominguez, Medical Coordinator with MSF based in Amman, told Syria Direct Tuesday that in cases of severe acute malnutrition, such as those afflicting Madaya residents, “it's really very specific supplements that you have to give. In general, we work with some ready-to- use, therapeutic food that is much more rich in protein but [has] some balance” and contains micronutrients.

“I don't have any treatment available,” said Yusuf, the head of Madaya’s Medical Society. “There are no eggs, no milk, no meat and no fruit.”

The WFP, responsible for providing food in the humanitarian deliveries, told Syria Direct Tuesday that “our food baskets do not include fresh fruits or dairy products due to the safety issues and the storage and the long times it take to deliver food to the people in the besieged areas.”

Aid organizations in Syria face trouble tailoring aid to the needs of residents in besieged or hard-to-reach areas, Pawel Krzysiek, spokesman for the International Committee of the Red Cross, told Syria Direct Tuesday. In Madaya's case, teams could not get in to do an initial nutritional assessment or conduct follow-up visits “because the parties couldn't agree,” said Krzysiek, without elaborating further.

“It's not surprising that Madaya is starving again,” Marjolein Wijninckx, Syria Programme Manager at PAX, a peace organization that has been supporting Syrian civil society since 2003, told Syria Direct on Tuesday.

“Negotiating humanitarian access with the very power that imposes the siege has very little chance of success,” Wijninckx said.

The ICRC, which contributed medical, not food, supplies to the aid caravans, defended the aid deliveries coordinated by the UN. “It was the first delivery, emergency delivery, so you always go for the standard package because you don't know what the situation on the ground will be,” Krzysiek said.

The Red Cross, Syrian Arab Red Crescent and WHO have managed to get medical teams into Madaya since January, but they do not treat residents inside, said Darwish. Instead, they monitor and record patients' information, “and say that these patients need to be evacuated and taken to hospitals” outside Madaya.”

“They [the Red Cross, Syrian Arab Red Crescent and WHO teams] say that are trying to pressure the UN to get them out but have received no response,” said Darwish, the Madaya-based doctor.

The WHO has received reports of “possible edema [bloating] cases” from the WFP, WHO spokesman Jasarevic said, but “we are not in a position to confirm this until medical examinations have been conducted by specialized medical staff.”

Jasarevic told Syria Direct Wednesday that the UN agency “is constantly advocating and submitting requests for the Syrian Arab Red Crescent mobile clinics and medical teams to re-enter...and evacuate patients requiring hospital treatment.”