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This report is produced by OCHA Syria in collaboration with humanitarian partners. It covers the period from 21 March to 31 March 2019. Situation reports on Al Hol camp are published bi-weekly. The next report will be issued around 15 April 2019.

HIGHLIGHTS

• As of 31 March, the population of Al Hol camp is 73,041 (21,245 households). Some 65% are children under the age of 18, and 27% are women. New arrivals since 4 December 2018 are 63,323.

• The number of new arrivals has significantly reduced in the reporting period, with only 500 new arrivals in the past week. Current capacity for hosting additional arrivals in communal areas and big size tents is at 2,000. If future influx is greater than that, initial shelter cannot be guaranteed. Approximately 100 people are sheltered in the reception center, close to a medical center, due to their medical condition.

• Humanitarian needs are still considerable across all sectors, and significant resources and efforts of donors and humanitarian actors are needed to sufficiently scale up the response. Humanitarian actors have in some cases redirected resources from other parts of the country in order to respond in Al-Hol.

• The latest new arrivals in particular, are in critical health conditions, with the capacity at referral hospitals overwhelmed. There is an urgent need for expanded health services in the camp itself, with approximately 30-50 cases, mainly treatment of injuries and malnutrition, referred to hospitals in Al-Hasakeh on daily basis.

• 43% of the camp population are Syrian IDPs, 42% are Iraqi nationals and 15% are other third country nationals. Most have suffered from prolonged exposure to hostilities and the strain of the journey from Baghouz, with many having specific needs, including pregnant women and girls, people with disabilities and more than 350 unaccompanied minors.

• Al-Hol camp presents a number of complex protection challenges. The size and the profile of the population requires expanded protection services. Access to the Annex hosting third country nationals remains regulated by camp authorities, and some restrictions are limiting humanitarian services. Concerns remain about the lack of male and adolescent boys above the age of 15 arriving at the camp and for their safety and well-being. Women and adolescent girls continue to need various forms of assistance to preserve dignity, prevent GBV, and respond to the effects of violence and abuse. Older persons, persons with disabilities and those with mental health and psychiatric needs remain among the most neglected population groups.

• Humanitarian partners are currently working at full capacity to expand the camp to accommodate the most recent arrivals and minimize time spent in communal living areas or big-sized tents. New phases, 6 and 8, are being prepared. The Annexes that host third country nationals are also being expanded in order to host additional people and improve living conditions. Enhancing shelter and WASH facilities and services are key priorities.

• Suar transit-centre has been closed and its resources, including big size tents, health and WASH facilities, are to be moved to Al Hol camp.

73,041 Total number of camp residents

92% Out of total camp population are women and children

15% Of camp residents are third country nationals (non- Iraqis)

14,700 Patients have received medical care

355 Unaccompanied minors/separated children

1,722 Hospital referrals since 1st March 2019

SYRIA: HUMANITARIAN RESPONSE IN AL HOL CAMP Situation Report No. 1 As of 28 March 2019

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SITUATION OVERVIEW

• In less than four months, Al Hol camp has gone from hosting some 10,000 people, back in December 2018, to hosting more than 73,000 people, far exceeding the planned capacity of the camp of approx. 41,000 individuals.

• Although the number of new arrivals has reduced during the reporting period, the latest arrivals continue to show signs of distress and suffer from conflict-related injuries, malnutrition and fatigue caused by exposure to months of hostilities and a lack of access to basic goods and services.

• Despite an on-going massive scale-up of life-saving assistance and services in the camp, challenges remain. More than 19,000 people, or 5,720 households, remain in big size tents, rub halls and communal spaces as humanitarian actors seek to further expand the camp through phases 6 and 8 and the Annex, and move people to family tents which should take place in the next two weeks.

• Medical teams are working 24/7 to provide primary and secondary health services, reproductive health and malnutrition support and facilitate referral to hospitals. During the reporting period, more than 350 patients were referred to hospitals in the area, many struggling to accommodate the huge caseload. The limited space for referral remains a key challenge with efforts needed to further strengthen the in-patient capacity of hospitals in Al-Hasakeh governorate.

• Ensuring access to clean water and hygiene services in a camp of more than 73,000 people remains a challenge. More than 1,500,000 liters of water are delivered to camp residents every day.

• Overcrowding, family separation and disruption of safety-nets are putting women and girls at risk, including gender- based violence. The fact that more than 90% of camp residents are women and children under the age of 18, calls for specific protection measures such as structured psychosocial support, interim care arrangements for unaccompanied and separated children, family tracing and reunification procedures.

• Further access is required for humanitarian actors to provide sustained health and protection services in the Annexes hosting third country nationals.

• On 21 March, services were temporarily halted or relocated, following clashes between some of the displaced and local security forces. Shootings were reported along with one death and eight injured. The security situation in the camp remains tense.

• Member states and humanitarian actors should initiate discussions to promote durable solutions for the displaced, including the repatriation of third country nationals. The surveying and clearance of explosive hazards in southeast Deir- Er-Zour governorate will become a priority down the line, as the displaced start to return to their areas of origin. International Conventions are clear on the responsibilities of parties to the conflict in clearing, removing and destroying explosive remnants of war once hostilities cease.

FUNDING

• To sustain the humanitarian response, the UN and humanitarian partners call on all member states to continue providing support to humanitarian actors responding in the area and to facilitate efforts to further scale up assistance.

• UN agencies supporting the population in the camp are appealing for an additional US$ 27 million to support the needs of the current population over the next months, including the scaling up of shelter and WASH and to be able to sustain assistance efforts to meet the nutritional, health protection – including child protection and GBV - and food needs of the

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camp population. Northeast Syria NGOs are also reaching out to donors to request additional funding and continued flexibility to redirect existing funds.

• The Syria Humanitarian Fund (SHF) has been mobilized with $16 million in reserve allocations to support the protection, health, shelter, NFIs, WASH, nutrition and education sectors. Given limited funding available, this will only partially cover the scale of needs. Humanitarian partners are also re-directing existing resources from other parts of the country to respond to the emergency. These will need to be replenished to ensure other populations in need receive assistance.

HUMANITARIAN RESPONSE

Health

Needs:

• There is a need to increase the number of medical mobile clinics (three), static medical points (six) and ambulances (two).

• Scale-up the overall Reproductive Health services and enhance the referral pathway as well as capacity of secondary health care and trauma. Scale-up of health promotion and health education is needed.

• Sustainable supply chains of trauma supplies and essential medicine to Al-Hol camp, especially in triage area.

• Enhancement of in-patient capacity of Al Hasakeh national hospital.

• An increased number of Mental health and psychosocial support staff are needed as part of fixed/mobile health teams.

• Expansion of disease surveillance systems across the camp and regular reports on the camp.

• More coordination with nutrition sector to follow up on discharged cases to avoid relapses.

• The establishment of an additional stationary health point inside the Annex, with capacity to provide life-saving and life- sustaining health assistance needs to be expedited, as well as a transparent referral pathway for foreign women and children to be hospitalized outside the camp.

• More trauma specialists, surgeons, paediatricians, gynaecologists and midwives are needed.

Response:

• Reception area offers 24/7 health services, while other phases do 12 hours per day.

• Communication for Development activities, including immunization, are ongoing. Ten health educators are currently on the ground with more to come.

• Vaccination is ongoing and teams are trying to cover all phases including triage/reception area and the Annex. According to MoH, between 9 December 2018 and 21 March 2019, 12,686 children under the age of five have been vaccinated, out of approximately 18,200. This includes 741 out of 2,480 children in the Annex. In total in Al Hol camp, 12,657 children have been vaccinated against polio and 5,302 against measles, while 4,986 children were vaccinated with IPV.

• The network of engaged private hospitals was expanded, including two hospitals in Qamishli city, and a specialized team consisting of surgeons and nurses was established to scale up referrals of emergency cases.

• Ongoing operational and technical discussions with health actors on establishing a field hospital. MSJM field hospital with two rub-halls with a 35-50 bed capacity, is being prepared, pending an identification of a location.

• Health and protection sectors are coordinating to mainstream protection in current health services.

• Ongoing discussions to enhance and maximize the capacity of secondary health care and trauma patients.

• Experts deployed to support partners and provide additional technical support to teams on the ground.

• Situation updates, health mapping services, reproductive health services, communicable diseases reporting mechanism and gaps on referrals.

• Discussions and assessments are ongoing on establishing an additional new field hospital.

Gaps & Constraints:

• Additional/top-up funding required to support referrals to private hospitals.

• High pressure and burden on current health facilities and limited capacity of secondary healthcare and trauma facilities.

• Access to the Annex for third country nationals remains a challenge for some health partners. Approximately 100 non- ambulatory trauma cases in the Annex are at risk of developing infection.

• Insufficient number of mobile clinics and static medical points. Shortage of specialized doctors and other medical human resources.

• Sufficient supply chain of medicines and consumables for all engaged health teams. Reliance on airlifted medicine and equipment supply chains.

• Limited capacity of hospitals in Al-Hasakeh for referrals from Al-Hol camp poses a challenge. Two additional hospitals have been contracted.

Food Security

12,686 Children under five

vaccinated

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Needs:

• Needs in the camp are being met with monthly food rations and ready-to-eat rations. In terms of long-term food security, the number of facilities for residents to prepare their own food needs to be bolstered.

Response:

• Response is ongoing, reaching all camp residents, through three lines of assistance; provision of cooked meals to new arrivals at the reception centres, provision of Ready-to-eat rations (RTE) - that last

up to 5 days, and provision of monthly food rations. Additionally, bread is provided on a daily basis. • There is capacity in the reception area to provide 2,000 meals a day to new arrivals. Current RTE stocks are at 11,908

packages. Pipeline Capacity of RTE is at 15,050 packages, with each package expected to last a family of 5-6 for up to a week.

• As of 1 April, 16,100 households or 61,750 individuals have been assisted with cooked meals, 18,880 households or 63,323 individuals have been assisted with RTEs and 21,245 households or 73,041 individuals have been assisted with monthly food rations. Additionally, in March, 469,012 kg of bread have been provided to 61,750 individuals or 16,100 households per day during March.

• Monthly food ration capacity stands at more than 21,245 households (73,041 individuals) per month, until June.

Gaps & Constraints:

• As per stock update from partners, the sector does not foresee any critical gaps in food assistance in the near future. However, come July, a food pipeline break is foreseen due to a funding gap. A four month lead time to import food to the country poses a possible gap.

• Cooking facilities are a key gap in terms of stoves and areas to prepare food. Current gap of communal kitchens is 206.

• Access to markets is constrained for Annex residents, due to approval procedures.

Shelter/NFIs

Needs:

• Current need for shelter plots is 1,368, which will increase in the event of further arrivals. Future arrivals will continue to require basic non-food items; including mattresses, blankets, jerrycans, solar lamps, and boots.

Response:

• In order to meet shelter needs, partners mobilized all available resources including family tents, big size tents and rub halls. Since December 2018, 209 big size tents, 7 rub halls and more than 10,653 family tents have been installed.

• More than 18,000 NFI kits and winter clothing kits have been distributed to the newly displaced population in the camp. Due to cold weather, winter assistance is being continued despite initial plans to stop in mid-March.

• Site preparation for further camp expansion is in progress. The expansion of the Annex, of 700 additional plots, is underway. Demarcation and work on WASH has started in phases 6 and 8. Both phases should be ready by mid-April.

Gaps & Constraints:

• The pace of the camp’s extension has not matched the fast influx of new arrivals. As a result, more than 5,700 households (19,000 people) live in shared accommodation, including large tents and communal areas.

• Tent distribution is suspended due to lack of space. The number of family tents available/in the pipeline is 8,336. There is no gap of family tents. Current gap of plots for tents is 1,368.

• With the available space in phase 5, 6 and 8; a total of 3,032 family tents can be installed, which is not sufficient to accommodate all those currently being hosted in shared accommodation.

• Non-food items are available and no gap is expected except for solar lamps and rechargeable fans; both are in the pipeline.

Nutrition

Needs:

• The nutrition sector will target up to 25,000 children under the age of 5, and 5,651 pregnant and lactating women (PLW). Detection and identification of malnourished children under the age of five and PLW is key, alongside prevention feeding programs and treating malnourished children.

• Need to enhance referral mechanisms to Stabilization centers for SAM cases with complications.

• Integration with health and protection sectors regarding unaccompanied children’s referral and raising awareness on malnutrition services.

11,908 Current Ready-to-eat

stock

10,653 Family tents have been

installed since December 2018

25,000 Children under the age of

five to be targeted

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• As of 23 March, 558 MAM cases, 249 SAM cases without complications and 308 SAM cases with complications, detected in the camp; most among recent arrivals.

Response:

• A Nutrition-feeding center is opening in phase 1, with a capacity of 8-10 beds.

• Establishment of three OTPs to cover the entire camp; one is in place, two are underway.

• SAM without health complications and MAM are treated and followed up on inside the camp. SAM cases with health complications are referred to SC and followed up until discharged.

• Three mobile teams, consisting of nutrition nurses, are operational. Seven more are in the pipeline.

• Training of community volunteers on the use of MUAC tape for early identification of malnutrition; 24 volunteers are already trained and more than 170 are to be trained.

• Breastfeeding counselling for lactating mothers is to start. Awareness campaigns on breastfeeding and complementary feeding are taking place. Number of baby-friendly spaces in the camp is to increase to two per phase, to encourage mothers to breastfeed children younger than 6 months.

Gaps & Constraints:

• The huge increase in numbers of camp residents and insufficient response capacity is creating gaps in provision of nutrition services. There is shortage of screening volunteers, specialized lactation consultants, nurses and pediatricians. To boost capacity to reach all children under 5 and PLW, nutrition partners need to rapidly scale up.

• A single SC in Al-Hasakeh is receiving all children with complicated SAM cases. There is a possibility of two additional stabilization centres in Al-Hasaekh and Al-Haya hospital but those are unreachable through the transporting agency. Field hospitals with stabilization centres are being proposed for easy access and timely referrals.

• The number of MBA’s and breastfeeding counsellors, currently three, is insufficient. Each phase and annex in the camp should as minimum have one or two.

Protection

Needs:

• The decline in arrivals in the past week have not completely reduced the demand for emergency activities such as identification of needs, immediate referral and information. At the same time, more structured forms of assistance remain in high need to build a systematic response to satisfy needs that will become protracted.

• The situation of children continues to be at the forefront. The number of unaccompanied minors/separated children (UASC) has risen further, with 355 identified so far. Interim care arrangements and a full range of emotional and psychosocial support interventions, family tracing and reunification procedures, case management for the most complex situations, follow-up on hospitalization to maintain family unity - remain in high demand. This month, approximately 280 children were provided with caregivers during treatment in hospitals. Protection services, supporting the comprehensive well-being of children should be scaled up to specifically address the complexity of interim care arrangements as well as family tracing and reunification.

• Women and adolescent girls continue to need various forms of assistance to preserve dignity, prevent GBV, and respond to the effects of violence, psychological and physical abuse. GBV support should be integrated with interventions in the field of reproductive health to detect and respond effectively. Female staff to ensure better reach are needed.

• Older persons and persons with disabilities remain among the most neglected and unsupported population groups, at risk of exclusion from assistance, deprived of well-being and dignity.

• Access to the Annex hosting third country nationals remains regulated by camp authorities, impacting the ability of some partners to respond. There is a need to avoid lengthy procedures to guarantee effective presence and principled approaches respecting confidentiality and “do no harm”.

• The need for GBV services, possibly integrated with Reproductive Health and delivered through mobile teams is urgent. Same goes for the need for dignity kits for women, including lactating women, adolescent girls and boys.

• There is a need for WASH facilities in line with best practices in GBV risk mitigation ensuring adequate lighting; gender segregated facilities disaggregated as well as locks suitable for children and other items to enhance protection and security for women such as solar lamps.

• Psychological first aid and specialized psychological support needs to be scaled up, as well as case management by qualified GBV managers.

Response:

• Four GBV mobile teams now operate in the camp; in the reception areas and in phases 1,3,4,5, and 7. RH and GBV teams provide services around the clock, seven days per week. Two Women and Girl Safe Spaces are open, with a third one soon to be established, likely in phase 4.

• A GBV mainstreaming training for humanitarian actors is being organized.

• Procurement of adult diapers is ongoing.

56 Unaccompanied/separated

children have been reunited with their families

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• Volunteers continue to cover areas where new arrivals have been settled; identifying needs, referring cases and providing information on services. Information desks are in the reception area and phases 3, 4, 5, and 7. Improved procedures are being put in place to streamline communication and analysis of requests, to support advocacy or remedial action.

• Protection teams continue to identify children in need, UASC in particular, and to follow up on hospitalized cases. Out of 355 UASC, 56 have been reunited while 105 remain in three interim care arrangements while tracing and reunification is being pursued. Six Child friendly spaces and two mobile teams are operational.

• Coordination arrangements continue with improved synergy between all protection actors, both Qamishli-based and cross-border. Sectors are backstopping field response.

Gaps & Constraints:

• Children suspected of having been associated with ISIS or other armed groups need to be provided with the care and protection they are entitled to under IHL.

• While the number of protection volunteers remains insufficient, it’s necessary to avoid removing protection volunteers from phases that pre-date the Hajin and Baghouz influx, where services need to continue.

• Based on population and current presence, it is estimated that some eight additional Child friendly spaces may be needed in the camp, complementing the current six existing and two in the pipeline. Similarly, some 7 additional women and girls safe spaces may be needed across the camp, complementing the two that are operational.

• There is a critical gap across the camp in provision of support for older persons and persons with disabilities through dedicated staff and mobile teams. No staff is currently deployed.

• Although substantial progress has been made in sorting documentation confiscated by camp authorities, stored in an archive in the camp, many documents remain unmatched with the list of arrivals. Efforts are still required in sorting documentation and correcting errors in the “identification database”. The challenge demonstrates the negative effects of the policy of confiscation, which continued to be implemented notwithstanding prolonged advocacy by protection actors against it.

• The size and the profile of the population requires a substantially increased protection presence and an expansion of services, with reference to more structured interventions such as psychosocial support, case management, restoration of complex family links, specialized support for person with disabilities including war injuries.

Water, Sanitation and Hygiene

Needs:

• To ensure regular access to critical WASH services, hygienic behavior and offer a safe environment to camp residents, a number of needs have to be urgently met. Over 18,500 hygiene kits per month, along with other WASH replacement items such as diapers and sanitary napkins, are required.

• Clear division of labour and full commitment of WASH partners is required to maintain cleanliness and functional status of already installed +2,500 latrines and bathing facilities.

• There is an immediate gap of +800 water storage tanks and a gap of +1350 for medium term, for ensuring regular access of water supply in all WASH facilities. In addition, over 400 solid waste containers, hygiene awareness campaign including solid waste management and vector control, are other areas of concern, primarily in new areas such as the transit area, annexes and phases 7 and 8.

Response:

• WASH partners deliver more than 1,516,000 liters per day (an average of 20 litre per person per day), for drinking and washing to all the displaced.

• Installation of 468 latrines has been completed while over 400 latrines/bathing facilities are under construction to meet 1:50 ration emergency standard. In addition, 475 water tanks are in place and over 170 are being installed. Some 620 solid waste containers (100 liter capacity) have been delivered with additional 200 in the pipeline.

• Cleaning and maintenance of WASH facilities, small scale hygiene promotion, solid waste management, fumigation and disinfection are currently ongoing but need to be further improved in a sustainable manner.

• In the reporting period, a total of 64 latrines were installed in phase 5, 40 in phase 7, eight in the reception area and 52 latrines in Annex 2. A total of 96 latrines are under construction in Annex 3.

Gaps & Constraints:

• A gap of over 1,350 toilets/bathing facilities to reach the 1:20 standard ratio of Al-Hol camp prior to the latest influx of people.

• A monthly delivery of hygiene kits is urgently required.

• Lack of commitment and assurance of partners to ensure and maintain cleanliness and timely repair/rehabilitation of already installed WASH facilities and sustained solid waste management in the camp.

Education

1,516,000 Liters of water delivered per day in Al-Hol camp

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Needs:

• The total number of school-aged children in the camp is approximately 26,000, of which the majority have been out of school for at least five years.

• The place of origin, nationality, learning needs and language barriers vary, hence a targeted intervention is needed to meet education needs.

Response:

• Non-formal Education programs are currently provided to approximately 4,000 school-aged children in five temporary learning spaces in phases 1, 3 and 4.

• To better understand the number of school-aged children and their learning needs, a joint assessment is underway to identify the number of children aged 6-19. This will inform the response and support coordination amongst partners.

Gaps & Constraints:

• Space for temporary learning, to run Education in Emergencies, is still not available in an overcrowded camp.

• Education needs in Al-Hol camp are beyond the capacity to respond, due to the lack of resources for scaling up education activities and the sheer scope of needs.

Early Recovery

Needs:

• Cash-for-work opportunities are needed and support is required for home-based female artisans and producers.

• Risk reduction related to accumulative waste, particularly in terms of Leishmanias, that may cause a serious public health impact.

• Rehabilitation of camp market and establishment of workshops.

• Initial assessments indicate that the number of people with disabilities (PWD) is between 575-600 among the displaced, most in urgent need of specialized assistance.

Response:

• Focus on providing short-term employment opportunities to ensure that affected households are directly involved in their own recovery while assisting normal economic activity.

• Solid waste management through a cash-for-work modality is to be carried out, covering phase 4, 5 and 7, creating 94 job opportunities with an estimated 3,120 tons of waste to be removed, in parallel with fumigation and spraying against sand flies. A particular focus on female headed households. Solid waste management of other phases is being planned.

• Plans to rehabilitate the camp market and support PWD with a training on maintenance of kinetic aids in addition to tool kits.

• Ongoing vocational training through community centers targeting 135 beneficiaries.

• Ongoing tent-maintenance workshop under cash-for-work modality targeting 60 beneficiaries. Gaps & Constraints:

• There is a need for livelihood services in newly created camp areas.

• Comprehensive services for elderly people and people with disabilities across the camp.

• Enabling the displaced to become self-reliant, through vocational training to support them to be productive members of society in which they reside now as well as future ones.

26,000 School-aged children in

Al-Hol camp

600 People with disabilities

and in need of assistance

For further information, please contact: Hedinn Halldorsson, Public Information Officer, hedinn.halldorsson@un.org, + 963 953 300 078 For more information, please visit https://www.unocha.org/syria

Background on the crisis The military escalation in Hajin and Baghouz in Deir-ez-Zour governorate that started in September 2018, triggered a massive internal displacement of a population that has been exposed to intense hostilities and lived in a situation of extreme deprivation and protection concerns. The number of people leaving Baghouz in past months has exceeded all expectations. More than 60,000 people, have been transported to Al Hol camp in Al-Hasakeh governorate since December 2018 and more than 9 in 10 are women and children in dire condition. The influx of displaced people has stabilized, as of end of March, but challenges remain for humanitarian actors to respond to the vast scope and scale of needs of 73,000 people. Overall, the humanitarian situation in the four governorates in the northeast, Al-Hasakeh, Deir-ez-Zour, Ar-Raqqa and parts of Aleppo, remains fluid and complex, with an estimated 1.6 million people in need. Humanitarian partners are currently reaching approximately 600,000 people with assistance every month.