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When the mother of a dying 3-year-old girl asks Amani Ballour if there is anything she can do to help, she doesn’t know what to say.
The girl, Rama, is a regular patient at the hospital, where Ballour works as a pediatrician in Eastern Ghouta, a Damascus suburb that is besieged by forces loyal to Syrian President Bashar al-Assad.
Rama suffers from nasopharyngeal cancer, a rare disease that starts in the upper part of the throat behind the nose. She is barely able to eat and has to come to the hospital regularly to get nutrition via a feeding tube. She needs medication and surgery that no one can provide for her in Eastern Ghouta -- and the siege prevents her from leaving for treatment.
“The truth is that I can’t do anything for her,” Ballour, 30, told ABC News in a voice recording in Arabic. “That’s the most difficult thing about our job. In many cases, we are paralyzed.” She said that Rama hasn’t been able to take the medication she needs for eight months.
“She could die within days,” said Ballour.
Last week, the United Nations said that world powers should urgently help arrange the medical evacuation of 500 people, including 167 children, from rebel-held Eastern Ghouta, saying that the area has become a “humanitarian emergency.” In recent weeks, nine people died while waiting for permission from the Syrian government to be evacuated from Eastern Ghouta, the U.N. said. An estimated 400,000 people are trapped there in urgent need of food, clean water, gas and health supplies. Few people there have more than one meal a day.
In recent months, the government has tightened its siege of Eastern Ghouta, and three weeks ago it intensified its military campaign there. At least 193 civilians, including 44 children and 21 women, have been killed by airstrikes and shelling during those three weeks, according to the Syrian Observatory for Human Rights, a U.K.-based monitoring group.
On Sunday, Syrian warplanes struck several residential areas in Eastern Ghouta, killing 27 civilians, including nine children -- the biggest daily death toll since the intensified campaign began, said the Syrian Observatory for Human Rights (SOHR). The airstrikes are so frequent that children no longer go to school, residents told ABC News.
Injured and malnourished children
Ballour said she sees injured patients every day, many of them children suffering from burns or in need of amputations. One of her patients is Abdurahman, a boy who’s about 10 or 11 years old, said Ballour. He arrived to the hospital along with a group of other children after an attack on their school. Abdurahman saw some of his friends die and lost both his legs in the attack, Ballour said.
"He went to school with both his legs and came back without them," she said. "He used to be a very energetic and enthusiastic child who really liked going to school. Now he's just sitting in bed. He can't get up."
Among her other patients is 1-year-old Yasmin who suffers from heart disease and needs open-heart surgery, which can’t be performed in Eastern Ghouta.
Ballour has also seen a big increase in the number of malnourished children because families have little access to food.
“The malnutrition cases are very painful for us. The parent bring their kids and say, 'We don't have anything to feed our children,'" she said, adding, "How can I cure any disease if the child is not eating?"
The acute malnutrition rate among children in Eastern Ghouta is nearly 12 percent -- five or six times as high as in January, said Jan Egeland, special advisor to the U.N. Special Envoy for Syria, in a news conference on Nov. 30. In the past two months, the U.N. has delivered aid supplies to only 68,000 of the 400,000 civilians trapped in Eastern Ghouta, he said.
Hospitals are missing the most basic equipment and are subjected to attacks, according to aid organizations and local health workers. Ballour's hospital has been attacked several times, she said, most recently about 10 days ago in an airstrike that injured one member of staff. In a neighboring building, a mother and her four children were killed in the same attack, said Ballour.
Many medical workers also don’t have formal training. Ballour herself serves as a pediatrician and hospital manager even though the war prevented her from completing her residency. Even basic medicines such as antibiotics are not available most of the time -- and when they are they are very expensive, she said. She believes Eastern Ghouta has less than 10 percent of the medicine that the population needs. Children often have simple and preventable illnesses that evolve into serious diseases, she said.
In addition to children with serious injuries and life-threatening diseases, Ballour meets children with deep mental scars.
"We meet children who have seen their fathers' and mothers' dead bodies," she said. "We meet children who were rescued from under the rubble. Sometimes they come out alive, but it leaves a big mark in the children's life."
Hytham Bkkar, a 38-year-old media activist in Eastern Ghouta’s city of Douma, said that on a normal day he’ll need to leave the house to look for wood for heating and flour for baking bread. But often airstrikes will prevent him from going out.
"My personal opinion is that it's a detention not a siege," he told ABC News in a voice recording in Arabic. "We are subjected to the same things that a prisoner is subjected to in a cell. We have a bigger area to move around in. That's the only difference."
When he does leave the house he knows that his 4-year-old son Elias will worry at home.
"He’ll ask his mom, 'Dad is late. What if he died? I hope nothing happened to him.' Yesterday I came home late and he said, 'Dad, we were worried about you. We thought you died,'" said Bkkar. "He says that on a daily basis."
Elias was born in late 2013, the same year that the siege was imposed on Eastern Ghouta. He hasn't known a life without war and siege.
"He knows warplanes and shelling and he knows how to hide in the shelter and what to do when there are airstrikes," said Bkkar. "When he draws something, he draws a warplane and dead people."
On Oct. 26, a plane dropped a bomb in front of Bkkar’s apartment, he said. His brother, nephew and three others died in the attack, he said. His home was damaged and it took 15 days to repair it.
Airstrikes part of daily life
There's no normal day in Eastern Ghouta, said Samira, a 45-year-old resident and aid worker who asked ABC News not to use her real name out of fear of repercussions. During a recent interview she said that rockets had just been fired close by after she left her office with a colleague to run an errand. The colleague, a young woman, froze in the middle of the street. Samira dragged her away into a store where they sought shelter. When they left there was another explosion and they hid in a different store.
"I'm now at the office," Samira told ABC News after the incident, in a voice recording in Arabic. "I have to go home, but I'm waiting for things to get quieter.”
The airstrikes often prevent her from going out when she wants to, but she still goes to work every day and attends weddings, as well as funerals, when she can.
"Every time you leave the house you know that there's a possibility that you may not return," she said. "Or there's a possibility that the people you leave in the house and the house itself will be gone when you come back. That is always on your mind."
A few days ago she was riding on the back of a motorcycle when an airstrike hit just one street away. Samira and the young man driving the motorcycle were on their way to see families so poor that they were staying in tents in the winter. Their plan was to find out the sizes of the children so that they could bring them clothes and shoes for the winter. The actual rocket didn’t hit their path, but the shrapnel did. Thick smoke filled the air.
"I told the young man, 'Can you imagine if we die here in the street?'" said Samira. The young man asked her if they should turn back, but she told him to continue.
Airstrikes had already forced them to postpone the trip many times, she said, and they had intended to bring the children clothes before the start of the winter. The young man drove fast.
"The civil defense and an ambulance also came driving and because of the smoke we didn't see each other and almost crashed," she said. "If we didn't die in an airstrike we almost died in a car crash."
One meal a day
Samira eats only one meal a day, in the evening, yet she describes her life as the life of a queen compared to many other residents of Eastern Ghouta. Samira has a water tank at home, which is a luxury in eastern Ghouta. She can afford to pay to have some electricity and internet. Most others can’t, she said. She also has a car, but she hasn’t driven it for about seven months because gas has become too expensive. One liter costs about 7,000 Syrian pounds, she said –- about $50 per gallon -- in a place where people either have little or no income.
"For the cost of gas you can feed a family," she said. "So it's better to feed a family or buy medicine for a sick person and walk rather than drive."
The last humanitarian aid to arrive in Eastern Ghouta was only enough to feed a family for four days if they had only one meal a day, she said. One woman who had been looking forward to having a cup of tea with some of the sugar that was included in the aid package told Samira that she ended up selling the sugar and the other aid she received. She spent the money on a cheap kind of flour so that she could make bread that would last her family for a whole month instead.
Every morning before she goes to the office Samira hosts women who come to her to share their concerns and ask for help. One of them has seven children and is raising her daughter’s two children. Their father died and their mother later remarried. The woman tries to earn a little money by cleaning people’s houses, but it pays very little, said Samira. Samira said she tries to help, but knows it's not enough -- she once gave the woman 3,000 Syrian pounds (about $6). The woman said she was going to shop for a dish with bulgur and tomato.
"She told me, 'I will buy bulgur for 2,000, and for 1,000 I will buy tomato, onions and a little oil. But then there's not enough money to buy salt,'" said Samira.
The 2,000 pounds would probably only be enough for about 2 pounds of bulgur, which wouldn't last the big family very long, said Samira.
Another woman who visits Samira has six children, one of them a 16-year-old disabled son who can’t walk. The mother has to carry him around, said Samira. Her husband was going to open a bakery with a business partner -– but his partner took all the money and fled. The husband now has a big debt and has to pay off $100 every month.
"But he doesn't even have one Syrian pound to pay every month," said Samira. The woman has sold all of her furniture except for one closet. The other day she had a fight with her husband because he wanted to sell the closet too, said Samira.
"She told me, 'If he sells the closet, where will I put my children’s clothes and notebooks?"
"I try to support the women mentally, but I often feel paralyzed," said Samira. "I help with very small amounts of money or if I have some food in the house that I can share I give it to them. But I know that it might only last them one day. I really, really feel paralyzed. A lot of people feel you should help them more, but you can only help them with very little that won't last long in Ghouta."