Every Minute We Are Expecting Our Deaths

Yarmouk Needs Assessment

June 2015

This assessment was commissioned by SREO to analyze the humanitarian and
security situation in the Yarmouk Camp in Damascus. SREO would like to thank the
respondents in Yarmouk for taking the time to provide honest and forthright
testimony about the challenges facing their community, as well as our field
researchers, who undertook data collection at significant risk in a highly dangerous
Max Marder, Daniel Seckman, and Matt Trevithick authored this report.

Photo Credit: Majdi Fathi



Executive Summary………………………………………………….…………….6
Geographic Scope and Sample..………………………………………….……..12
Data Collection….…………..…………………..……….…….………..………12
Respondent Demographics…………………………………….………..………..14
Humanitarian Access..………………………….………..…………….………..16
Water and Sanitation..………………………..…………..…………….……….17
Food Security and Livelihoods……..……….……………..……….……..…..……20
Most Urgent Needs.……….…….……….……….…..…….….………..……….26


SREO is an independent, non-partisan research center based in Gaziantep, Turkey.
SREO’s team of researchers includes Syrians, Turks, Europeans, and Americans who
have all spent significant time in Syria and the Middle East. Its researchers speak
local languages and are dedicated to providing objective analysis of what is
transpiring inside of Syria as well as in the host communities of neighboring
SREO provides monitoring and evaluation services along with needs assessments
and feasibility studies to organizations involved in the Syrian humanitarian
response. Together, the SREO team has more than two decades of research
experience from Afghanistan, Pakistan, Iraq, Syria and Turkey.
Contact: communications@sreo.org 


Aknaf Aknaf Beit al-Maqdis

Syrian Pounds


Besieged for more than two years, the approximately 18,000 civilians remaining in
the Yarmouk Camp in Damascus are among the most at-risk population in all of
Syria. Without electricity for two years, and without clean water for nearly a year,
residents of Yarmouk are also caught in the crossfire of a three-way conflict
between the Syrian government, the Islamic State, and Aknaf Beit al-Maqdis, a
Palestinian faction allegedly tied to Hamas. The resulting situation, with
respondents trapped and starving in a compact combat zone, makes Yarmouk one
of the most dangerous places in the world to live.
This assessment utilized 100 household surveys, conducted in Yarmouk at
considerable risk to SREO’s researchers, to assess the humanitarian and security
situation in the camp. The evaluation team was particularly interested in residents’
ability to access basic services, the types of coping mechanisms residents of the
camp have employed, the changes in the camp since the Islamic State’s offensive in
April, and the makeup of the armed groups fighting in the camp.
Respondents, often unanimously, confirmed the validity of recent reporting on the
situation in Yarmouk: the Syrian government has completely cut off access to
municipal water and electricity systems, no organization or group is currently
permitted to deliver humanitarian aid in the camp, and residents are struggling
daily to survive. All one hundred respondents indicated high concern for their
physical safety.
The situation in Yarmouk has only deteriorated further since the Islamic State took
control of parts of the camp in April 2015. Aid organizations, whose presence in the
camp was not government-approved in the first place, fled as the Islamic State
attacked water distribution points and medical centers.
Residents have generally adopted desperate coping mechanisms to adapt to their
situation. Most residents eat one meal per day and both children and pregnant


women were found to often skip meals. Without clean sources of drinking water,
residents often consume well water knowing full well that it is contaminated with
sewage. For lighting, residents use rechargeable lamps, but only when necessary
due to the high cost of the generators and fuel needed to charge them. With no
large functional medical facilities, parents have taken to treating their child with ad
hoc first-aid and traditional medicine.
While a slim majority of men surveyed were generating income, almost no women
had jobs. Trapped and under siege, livelihoods are in shatters. The average
household was surviving on less than $4 per day; the average person on well under
$1 per day.
The largest group fighting in Yarmouk according to respondents was Aknaf Beit alMaqdis, followed by the Islamic State and the Syrian government respectively. Eight
of the respondents were Aknaf fighters. Seven others had brothers or sons fighting.
The three most urgent needs reported by respondents were food, water and
medicine—without which they could not survive. Electricity was the fourth-most
urgent concern. Given the thin line between life and death in the camp, other vital
needs like education, shelter and livelihoods were considered luxuries.


Yarmouk, eight kilometers from central Damascus, is barely surviving a
humanitarian crisis. Despite camp residents’ neutrality in the first months of the
conflict, the violent crackdown by the Syrian government on predominantly
peaceful protestors and the highly politicized nature of the conflict inexorably
dragged the camp and its residents into the fray.
Before the conflict, the Yarmouk Camp, just two square kilometers in size, was
home to 180,000 Palestinian refugees from the conflict in 1948 and 1967, in
addition to hundreds of thousands of Syrian nationals. As of this writing, only about
18,000 civilians remain in Yarmouk, trapped, besieged and bereft of some of the
basic needs for survival.1 Those who stayed were disproportionately unable to seek
refuge elsewhere: the poor, the elderly, the sick, the injured and children.2 As of
March 2014, nearly two-thirds of Syria’s pre-conflict Palestinian refugee population
of 530,000 had been displaced for at least the second time.3
The Syrian government’s siege of Yarmouk began in December 2012, prompting
over 150,000 residents to flee the camp.4 The government cut off the main
electricity power supply in April 2013, further increasing strain on households and
medical facilities. Since July 2013, the Syrian government has prevented the entry of
people, food, goods and medicine into the camp, with only small exceptions.
According to Amnesty International, by March 2014, 194 civilians had been killed
due to starvation, a lack of medical care or government snipers. Many others have
been brought to the brink of death by illnesses, caused by malnutrition and
contaminated drinking water, or injuries sustained as a result of the fighting in the


“Syria: Squeezing the Life out of Yarmouk: War Crimes against Besieged Civilians | Amnesty
International USA.” Amnesty International, March 10, 2014. http://www.amnestyusa.org/research/reports/







camp. Forces loyal to the Syrian government often targeted aid workers and
medical personnel, and many disappeared mysteriously.5
The arrival of anti-government armed groups into the camp starting in May 2013
further complicated matters for civilians. Armed groups, including brigades aligned
with the Free Syrian Army, Jabhat al-Nusra, the Islamic State, raided medical
supplies. The groups’ presence has exposed civilians to higher levels of violence and
a further tightening of the siege by the government. According to Amnesty
International, however, armed groups were not preventing civilians from leaving the
siege area.
In January 2014, negotiations between the Syrian government, Yarmouk residents
and the Palestinian Authority produced an agreement under which the Syrian
government would allow sick and wounded residents to leave the camp, as well as
limited food parcels to enter the area.6 According to residents, the government has
since reneged on this agreement.
In early April 2015, the Islamic State launched its most significant offensive to date
in Yarmouk, engaging in heavy clashes with the main local Palestinian faction, Aknaf
Beit al-Maqdis, the latter of which is allegedly allied to Hamas and opposed to both
the Syrian government and the Islamic State.7 The Syrian government has
intensified shelling of the camp since the Islamic State gained a foothold.8 The head
of The United Nations Relief and Works Agency for Palestinian Refugees (UNRWA)
said these developments made the situation “more desperate than ever” for
trapped civilians in desperate need of food, water and medicine.9





“ISIL seizes most of Syria’s Yarmouk Camp,” Al Jazeera and AP, April 5, 2015, http://



“Islamic State-controlled Yarmouk refugee camp conditions ‘beyond inhumane,’” The Telegraph, April 7,
2015, http://www.telegraph.co.uk/news/worldnews/islamic-state/11519106/Islamic-State-controlledYarmouk-refugee-camp-conditions-beyond-inhumane.html


The siege of Yarmouk has continued, despite the passage of United Nations
Security Council Resolution 2139, passed in February 2014, which called for “all
parties to immediately lift the sieges of populated areas,” including Yarmouk.10


United Nations Security Council Resolution 2139, passed February 22, 2014, http://photos.state.gov/


The objective of this assessment was to complete a timely and informed
assessment of the humanitarian and security situation in the Yarmouk Camp in
Damascus since the Islamic State entered the area. SREO’s evaluation team
prioritized analysis on five indicators of the humanitarian situation in the city:
electricity, livelihoods, health, clean water and security. Another primary objective
of this assessment was to uncover what civilians’ greatest and most urgent needs
were during this fluid period. Additionally, this assessment sought to analyze
civilians’ attitudes toward the three faction vying for control of the Yarmouk camp:
Aknaf Beit al-Maqdis, the Islamic State and the Syrian government.


Geographic Scope and Sample
Field researchers surveyed respondents throughout the entirety of the Yarmouk
camp. During the evaluation period, field researchers conducted 100 structured
interviews with camp residents throughout Yarmouk. The assessment strove to
achieve gender parity in its sample, and was successful in conducting interviews
with 51 women.

Data Collection
The data for this assessment was based on a 20-question survey designed by
SREO’s evaluation team in Gaziantep, Turkey. The majority of questions were closeended, but open-ended and qualitative questions were included to allow
participants a wider range of expression and to supplement the assessment’s
quantitative findings.
Three field researchers completed 100 surveys in total. Surveys were administered
on paper, and each took approximately 10-20 minutes to complete. Field
researchers later transcribed the interviews into Microsoft Word documents. Once
they obtained a reliable Internet connection, field researchers transferred data to
SREO’s evaluation team in Gaziantep to begin analysis.
Field researchers worked individually, enabling the three of them to cover a broad
area of the camp and avoid attracting unwanted attention. Field researchers could
not administer surveys openly for fear of the Islamic State. Aknaf Beit al-Maqdis
fighters consented to participate in the assessment.
Respondents were identified on a random basis in the streets. Field researchers
worked to collect a random sample and to interview the young and old, men and
women, fighters and civilians, and residents of both poor and relatively wealthy


neighborhoods. Interviews were later conducted in the homes of the respondents
or field researchers to avoid the risk of arrest or detention.
Many residents were nervous and refused to answer the survey. However, the
majority of respondents were willing to participate in the survey once field
researchers assured that their identities would remain anonymous.
Of the 100 respondents, eight were Aknaf Beit al-Maqdis fighters. A handful of
fighters were selected in the sample given their visibility in the streets.
Field researchers faced several obstacles in their work. Many randomly selected
residents refused to participate in the survey out of fear. Mobility was often limited
by fighting and checkpoints, especially at night. However, field researchers
completed research without arousing the suspicions of armed groups. Occasionally,
when field researchers attempted to interview women, their male companions
spoke for them. Nonetheless, this evaluation managed to obtain gender parity.


The respondents for this assessment were evenly divided based on gender—49
men and 51 women.
Figure 1: Respondents by Gender

The average respondent was approximately 38 years old. The median age of
respondents was 37 years old, indicating a relatively normal age distribution.
Fourteen percent of respondents were under 20 years old and 12 percent were
over 60. Nearly three-quarters of the sample was between 20 and 60 years old.
Unsurprisingly, the age of the fighters trended younger. Six of the eight fighters
were 21 years old or younger. The oldest fighter was 36 years old.
Households surveyed tended to be large, with the average household containing
5.8 family members. Nearly half of the households surveyed (48 percent) contained
six family members or more.


Figure 2: Respondents by Age

Figure 3: Household Size


The humanitarian situation in the Yarmouk camp was found to be among the most
dire in all of Syria. The camp has been under siege, blockaded by the Syrian
government since July 2013.11 In April 2015, forces from the Islamic State entered
the camp and have taken partial control of Yarmouk, facing strong resistance from
Aknaf Beit al-Maqdis. Since then, the humanitarian situation has rapidly
deteriorated. Aid organizations came under attack from the Islamic State, which
also attacked water distribution points and medical facilities. In addition to
humanitarian needs, residents’ safety is highly at risk, as they are caught in a threeway fight between the Syrian government, the Islamic State, and Aknaf Beit alMaqdis.

Humanitarian Access
Residents of the Yarmouk Camp currently have no access to humanitarian aid.
Respondents were unanimous on this point: no organization or actor of any sort
was providing assistance in the Yarmouk Camp during the evaluation period.
Humanitarian organizations had been providing assistance in the camp until the
Islamic State arrived in April, 2014, and, according to respondents, prohibited
humanitarian assistance. Due to the threat posed by the Islamic State, which
included attacks both actualized and threatened, humanitarian actors fled to the
nearby suburb of Yalda. Several respondents indicated that even before the
cessation of assistance, materials provided were not sufficient to cover the needs of
Yarmouk’s residents.
Respondents also blamed the Syrian government for the lack of humanitarian
assistance in Yarmouk. They indicated that the government had reached an
agreement to allow humanitarian assistance into the camp, only to backtrack on
that promise once the Islamic State entered the area. The government has imposed

“Squeezing the Life out of Yarmouk: War Crimes Against Besieged Civilians,” Amnesty International,
March 2014, http://www.amnesty.eu/content/assets/Reports/


a blockade on the camp, preventing the movement of people and goods, since July

Water and Sanitation
This assessment revealed that there is no access to clean water in the camp, which
has been without municipal water since late 2014. Several respondents knew
exactly how long they had been without tap water — 260 days. Aid organizations
had previously been providing water for camp residents to make up for the
shortage caused by the state’s cuts, although respondents indicated that the water
supplied was never enough to meet the needs of the camp.
Figure 4: Main Source of Drinking Water

Forty-two respondents reported having no access to any water at all. The remaining
58 respondents said that their only source of water were public wells, which were
well-understood by residents to be contaminated and unsafe for drinking. Pipes
and other water infrastructure had been damaged in the fighting, tainting the well
water with sewage. Respondents reported that disease and epidemics were
common due to the dirty water, and that sickness had been spreading throughout 




the camp given the lack of medicine. However, respondents indicated they had no
alternative. Eight respondents indicated that residents also collect and drink rain
water. However, precipitation is sparse in the camp during the spring and summer

Out of the 100 respondents surveyed for this assessment, 78 reported that
Yarmouk had no access to functioning health facilities of any kind with two
kilometers. The remaining 22 respondents said that there was a medical point—a
small one-room health facility—but that it was ineffective because of
insurmountable capacity constraints and a lack of medical equipment, medicine
and personnel.
Figure 5: Functioning Health Centers Within 2km

Many respondents reported that there had been a hospital in Yarmouk, the
Palestine Hospital, which had been functioning until recently. However, the Islamic
State bombed the hospital after it entered the camp in April 2015, killing several


medical personnel who had been working there. Many doctors have subsequently
fled Yarmouk.
Figure 6: : Respondent Knowledge of Medical Personnel in Yarmouk

Only 20 out the 100 respondents reported knowledge of male doctors working
anywhere in the camp, and just two respondents knew of any female doctors
currently practicing in Yarmouk. Forty respondents knew of midwives operating in
the camp, and 57 knew of nurses. However, many of these respondents indicated
that there were only two of each currently active in the camp. Thirty-one
respondents had no knowledge of any health staff currently operating anywhere in
In lieu of formal medical services, several respondents reported that residents had
been performing “primitive” medical procedures on the sick and injured, as well as
applying first-aid.
Given the blockade imposed by the government, medicine is largely unavailable in
Yarmouk—all the more worrying because of the prevalence of disease caused by
residents drinking contaminated well water. Medicine was cited as the third-most
oft-cited concern among respondents.


Food Security and Livelihoods
Figure 7: Number of Household Meals per Day

Residents in the Yarmouk camp did not have easy access to food items, and not a
single respondent surveyed reported that members of their household ate three
meals per day. Sixty-three respondents said that their household only ate once per
day, while the remaining 37 respondents said their family ate two meals per day.
Households in the Yarmouk camp are unable to provide three meals per day for
their children. Eighty-seven respondents expressed that children in their household
were forced to skip meals, as opposed to only six respondents who said that their
children did not skip meals.
Figure 8: Percentage of Households in Which Children Skip Meals


The remaining seven respondents did not have children living in their household
during the evaluation period. Pregnant women were similarly forced to skip meals.
Twenty-four respondents reported that pregnant women in their household did not
eat three meals per day.
Figure 9: Number of Respondents Currently Working

Besieged and blockaded, income-generating opportunities in Yarmouk were
difficult to come by. The employment rate was much higher for men than for
women. Thirty of the 49 men surveyed were currently working at the time of the
assessment, compared to only five of the 51 women. Men were most commonly
fighters or owners of street stands. Women were most commonly teachers or
Respondents’ average household expenditures, on food and other basic needs, was
709 Syrian pounds per day. When dividing household expenditures by number of
family members per household, daily expenditures averaged 142 Syrian pounds per
person. Using May 2015 exchange rates (1 USD= 188 SYP), this totaled less than $4
per day spent on items for the household and less than $1 per person per day.


Figure 10: Household Expenditures per Day (SYP)

Figure 11: Household Expenditures per Person per Day (SYP)

The security situation in Yarmouk— characterized by fighting between the Syrian
government, the Islamic State and the Palestinian armed group Aknaf Beit alMaqdis— is extremely dangerous. All 100 respondents indicated that they were
concerned about their safety.
On the balance, Aknaf Beit al-Maqdis was the largest armed group fighting in the
Yarmouk Camp according to respondents, 64 of whom reported that Aknaf was the
largest group fighting in the camp, while 18 said it was the second-largest faction. 


Eight members of the sample were Aknaf fighters while seven others said they had
relatives who were members of the group. It is possible that affinity for Aknaf Beit
al-Maqdis caused respondents to inflate its size.
Figure 12: Three Largest Armed Groups Fighting in Yarmouk

The Islamic State was the second-largest group fighting in Yarmouk according to 74
of this assessment’s respondents. A minority of 22 respondents expressed that the
Islamic State was the single largest group fighting in the camp, while only five
respondents said it was the third-largest group.
The Syrian government, according to 77 respondents, was the third-largest group
fighting in the camp. Fourteen respondents said the government was the largest 


fighting group and eight reported that it was the second-largest group. However,
the Syrian government is still a major player in Yarmouk—despite it’s relatively
smaller presence inside of the camp, it exercises control in the area surrounding the
camp and has imposed on blockade on Yarmouk for almost two years.
Figure 13: The Syrian Government Prevents Households from Leaving

The vast majority of respondents (92 out of 100) reported that the Syrian
government did not allow households to leave the Yarmouk camp. Numerous
respondents indicated that government forces shot residents attempting to escape
from the camp.
Relative to the Syrian government, the other armed groups in Yarmouk were more
flexible in allowing residents to leave the camp. Only 40 of 100 respondents
indicated that armed non-government groups prevented households from fleeing,
indicating that it was likely the Syrian government, as well as old age, infirmities,
and injuries, which represented the main obstacles to residents’ ability to escape.


Figure 14: Armed Groups Prevent Households from Leaving Yarmouk

Respondents were unanimous in reporting that Yarmouk residents do not have
access to electricity from the national power grid, which the Syrian government cut
off in April 2013.13 Forty-one respondents indicated that generators represent an
alternative electricity source for Yarmouk residents. However, the high cost of fuel
for the generators render them unusable by the majority of the camp’s residents.
Several respondents reported that camp residents could access rechargeable lamps
for light. However, the lamps could only be recharged by using generators, the cost
of which prevented residents from using them except when absolutely necessary.
Respondents reported that access to fuel has only become more difficult since the
Islamic State entered the camp in April 2015. 




Most Urgent Needs
Residents of the Yarmouk Camp are in desperate need of basic goods for survival.
Food (84 of 100 respondents) and water (74 of 100 respondents) represented the
most-frequently cited needs of this assessment’s respondents. Over half of the
respondents (53 out of 100) expressed that medicine was an urgent need,
particularly because of the prevalence of disease linked to the consumption of
contaminated well water. Thirty-seven respondents mentioned the need for
electricity. While all respondents face electricity shortages, it is likely that the lack of
basic goods for survival took priority.
Smaller proportions of respondents expressed an urgent need for other items and
conditions, including: security and an end to the fighting in the camp (13 percent);
education (six percent); fuel (six percent); a return to normalcy (six percent); the exit
of the Syrian government and the Islamic State from the camp (five percent);
livelihoods (three percent); baby milk (three percent); and shelter (two percent).
Again, while it is likely that the vast majority of Yarmouk residents have the above
needs, most prioritized the most basic items for immediate survival—food, water,
and to a lesser extent, medicine.
Figure 15: Most Urgent Needs


After living under siege for two years, the situation for residents in the Yarmouk
Camp has continued to worsen, reaching some of the most desperate levels of
subsistence in Syria. The situation is characterized by a lack of access to basic needs
for survival, removal from the public water and electricity grids, and exposure to
extreme violence. The Islamic State’s offensive in the camp in early April 2015
brought a further deterioration, with the Syrian government tightening an already
tight siege while intensifying the bombardment of a trapped population dying of
starvation and disease.
Yarmouk’s residents have been without publicly provided electricity for over two
years and without municipal water for eight months. While residents have access to
generators, the high cost of fuel and lack of income generation prevents its use
except in the most necessary situations. Without any source of clean water since
relief organizations fled Yarmouk in April, residents have been drinking from wells
that they know are contaminated.
The average Yarmouk resident eats one meal per day, has no access to electricity,
clean water or medical services, and subsists on less than $1 per day. If they are
male, they probably have a meager income generating opportunity, and if they are
female, they are probably unemployed, unless they are one of the rare exceptions
that work as a teacher or a midwife.
Respondents reported that there are currently no humanitarian actors working in
Yarmouk Camp. While the Syrian government agreed in January 2014 to allow
supplies into the camp, it has since backed out of this agreement. Aid organizations
working without the permission of the Syrian government fled from the camp after
some of them came under attack from the Islamic State in April 2015. Even while
assistance was available in the camp, it was not nearly enough to cover the needs
of all of Yarmouk’s residents.


In the months since the Islamic State captured significant territory in Yarmouk,
residents have been caught in the middle of a triangular fight between the
Palestinian Aknaf Beit al-Maqdis, the Islamic State and the Syrian government. The
Palestinian faction was reported to by respondents to be the largest of the three
operating inside of the camp, and the Syrian government the smallest. However,
the Syrian government still has enough power concentrated around the outside of
the camp to continue to impose control over most of what comes in and out of the
camp. Indeed, 92 percent of respondents indicated that the Syrian government still
does not allow civilians to leave the Yarmouk Camp, in violation of UN Security
Council Resolution 2139.
In many ways, the Yarmouk Camp represents a microcosm of the Syrian conflict,
featuring routine violations of human rights law, reneged agreements, denied
access, inaccessible services, and no end in sight as intractable fighting between
bad and worse groups catches civilians in the crossfire.


“ISIL seizes most of Syria’s Yarmouk Camp,” Al Jazeera and AP, April 5, 2015, http://
w w w. a l j a z e e ra . c o m / n ew s / 2 0 1 5 / 0 4 / i s i l - s e i z e s - s y r i a - y a r m o u k - re f u g e e camp-150404135525226.html
“Islamic State-controlled Yarmouk refugee camp conditions ‘beyond inhumane,’” The
Telegraph, April 7, 2015, http://www.telegraph.co.uk/news/worldnews/islamic-state/
“Syria: Squeezing the Life out of Yarmouk: War Crimes against Besieged Civilians |
Amnesty International USA.” Amnesty International, March 10, 2014. http://
United Nations Security Council Resolution 2139, passed February 22, 2014, http://