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			 Yet it is months since convoys from the United Nations and other 
			agencies have delivered food or medical care to many such areas — prevented by a Syrian government accused of using hunger as a weapon 
			of war against its people. 
 			As the United Nations launched an annual appeal on Monday to help 16 
			million people affected Syria's civil war, divisions among world 
			powers that have crippled peacemaking are also denying U.N. staff 
			the power to defy President Bashar al-Assad's officials and push 
			into neighborhoods now under siege.
 			"In government-controlled parts of Syria, what, where and to whom to 
			distribute aid, and even staff recruitment, have to be negotiated 
			and are sometimes dictated," said Ben Parker, who ran the U.N. 
			Office for the Coordination of Humanitarian Affairs (OCHA) in Syria 
			for a year until last February.
 			"According to the Syrian government's official position, 
			humanitarian agencies and supplies are allowed to go anywhere, even 
			across any frontline," he wrote last month in the journal 
			Humanitarian Exchange. "But every action requires time-consuming 
			permissions, which effectively provide multiple veto opportunities." 
			Fighting and rebel groups are also obstacles. 			
			
			 
 			The United Nations appealed for $6.5 billion on Monday to help 16 
			million people affected by the Syrian civil war, including millions 
			made hungry and homeless by the conflict soon entering its fourth 
			year.
 			The world body estimates about a quarter of a million Syrians are 
			living under siege as winter bites, most of them encircled by 
			government forces, but also including 45,000 in two towns in the 
			north that are besieged by anti-Assad rebels.
 			A binding Security Council resolution could formally oblige the 
			authorities to let aid agencies into areas like the Damascus suburbs 
			and the old city of Homs, where local doctors say children are dying 
			of malnutrition. But divisions between Western powers, backing the 
			rebels, and Russia, have paralyzed the world body over Syria since 
			the conflict began in 2011.
 			As a result, international agencies are legally obliged to work with 
			a government which aid workers say has used threats — say, to deny 
			visas to foreign staff or hinder efforts to help millions of people 
			outside besieged districts — as a way of muting criticism and 
			discouraging attempts to break the sieges.
 			"It is a fundamental flaw in the international system that it is 
			possible for a rogue state to hold its own people hostage," said a 
			Western diplomat who works on aid issues.
 			"Syria ... can threaten access to its own population and say 
			'millions will starve if my instructions are not followed'.
 			"The reality is there is a risk of being thrown out," he said. "You 
			have to look ultimately at what the moral obligation is to serve as 
			many as you can."
 			"TROJAN HORSE"
 			As far as Assad's government is concerned, said former U.N. Syria 
			staffer Ben Parker, aid operations are "a Trojan horse to 
			delegitimize the state, develop contacts with the opposition and win 
			international support for military intervention".
 			To criticism that they should complain more loudly, aid workers 
			speaking privately cited the case of a U.N. agency chief who ended a 
			posting in Damascus last year after clashing with Syrian officials 
			over access for aid distribution. Syria had made clear that the 
			official's visa would not be renewed. 			
			
			 
 			An internal U.N. document seen by Reuters last month said visa 
			applications for international staff were more likely to be turned 
			down or put on hold in 2013 than to be approved.
 			It described Syrian bureaucracy hampering operations, as well as 
			difficulties posed by fighting and a lack of cooperation from 
			numerous, often rival, rebel groups across the country.
 			The International Committee of the Red Cross (ICRC) said this month 
			that both sides have blocked medical aid to the sick and wounded. 
			"Where we haven't been particularly successful is in increasing our 
			medical activities in Syria, which remain below our expectations," 
			ICRC President Peter Maurer said.
 			"On both sides we are struggling with the argument that whatever 
			medical aid is brought to one part or the other is interpreted as an 
			indirect military support to the other side."
 			Syrians in areas where little or no aid is getting through say they 
			feel abandoned and blame world powers for not only extending a war 
			that has killed over 100,000 by backing warring parties but also 
			failing to ease the impact on civilians.
 			An opposition activist in Damascus who uses the name Tariq 
			al-Dimashqi and works in a field hospital in the besieged eastern 
			suburbs of the capital says that he has seen no medicine or food 
			from the United Nations for more than a year.
 			"The United Nations should do something to save civilians," he said. 
			"They have to force the regime to end the siege."
 			Some medicines are smuggled in to the area, he said, but the 
			hospital is very low on supplies.
 			CHILDREN DYING
 			Lack of access for independent agencies makes it hard to verify food 
			and medical supplies in many areas. But opposition activists have 
			posted video of the bodies of several skeletal children who local 
			doctors say died of malnutrition.
 			In September, footage of the body of one-year-old Rana Obeid, ribs 
			protruding and belly swollen, was accompanied by statements from 
			doctors saying she was the sixth child to die from malnutrition in 
			Mouadamiya, about a quarter-hour drive from the Four Seasons Hotel 
			in Damascus. 			
			
			 
 			More broadly, providing aid across a patchwork of front lines across 
			Syria has proved a struggle. Of a population of 23 million, the 
			United Nations says 2.3 million refugees have fled the country, 
			taking the misery of the war into often fragile neighboring states, 
			while 9.3 million need help inside Syria.
 			Two million of these are in areas that are hard to reach.
 			
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			A 2013 U.N. appeal for $1.41 billion to finance aid work in Syria 
			reached only 62 percent of its target. U.N. humanitarian chief 
			Valerie Amos launch the funding appeal for 2014 on Monday for more 
			than four times as much money.
 			"This is the largest amount we have ever had to request at the start 
			of the year," she said. Twelve U.N. staff and 32 staff or 
			volunteers of the Syrian Arab Red Crescent have been killed and 21 
			U.N. staff remain in detention, last month's U.N. document seen by 
			Reuters says — without specifying which groups were holding them.
 			In a country in the grip of a population explosion before the war 
			began, half of Syria's needy are children.
 			"The time will come that whatever aid you bring it is far too late 
			and the scars on children will be far too deep to repair," said 
			Maria Calivis, Middle East and Northern Africa director for the U.N. 
			Children's Fund UNICEF.
 			This month the U.N. failed to deliver food to 600,000 out of its 
			monthly target of 4 million, a goal never yet reached.
 			Of 91 public hospitals in Syria, 36 are not functioning and another 
			22 have been damaged, while almost half of the 658 ambulances have 
			been stolen, burned or massively damaged, according to the World 
			Health Organization (WHO).
 			The domestic drug industry — largely based in some of the areas 
			hardest hit by fighting — collapsed in August 2012 and has virtually 
			halted production, the WHO added. Rights groups say the Syrian air 
			force has deliberately bombed hospitals.
 			The WHO said last month that polio, which is incurable and paralyses 
			children within hours, had spread from the eastern city of Deir 
			al-Zor to the major city of Aleppo and around Damascus. It is the 
			country's first outbreak since 1999. 			
			
			 
 			The WHO must work through the government and a vaccination drive has 
			not reached all areas, although the agency says 600,000 people have 
			been reached in contested areas.
 			"The pressure has to be kept on" for access for medical supplies, 
			said Elizabeth Hoff, the WHO representative in Syria.
 			"POOR" RESPONSE
 			Lebanon-based public health researchers Fouad Fouad and Adam Coutts 
			criticize the local and international response:
 			"The outbreak and now spread of Polio Type I in Syria represents 
			more than just a breakdown of a public health system during a time 
			of conflict," said Coutts.
 			"It is symptomatic of a humanitarian response in which public health 
			has been neglected and which remains underfunded and poorly 
			coordinated."
 			Fouad said more than 70 percent of medical staff have left Syria due 
			to the crisis and that no data is being collected on mental health 
			inside Syria. Mental health care is a neglected area and a 
			"heartbreaking" challenge, the WHO's Hoff said.
 			Leishmaniasis, a disease transmitted by sand flies which causes 
			sores on the skin, is spreading so fast it has earned the local 
			nickname the "Aleppo boil".
 			In Aleppo, once Syria's most populous city, Fouad said no one had 
			had heart surgery in more than a year: "This is not a new crisis. 
			This is not the first conflict," he said.
 			"The U.N. should be doing better."
 			Peggy Hicks, the head of advocacy for lobby group Human Rights 
			Watch, said that U.N. efforts have lately made some modest progress 
			in eliminating bureaucratic obstacles to aid.
 			"But with winter fast approaching, these grudging steps by Syria are 
			nowhere near enough," she said.
 			"The U.N. should keep emphasizing that the real test is a change in 
			the situation on the ground, particularly for the 280,000 Syrians in 
			besieged towns." 			
			
			 
 			On Oct. 2, the U.N. Security Council urged the Syrian government 
			in a non-binding statement to allow immediate cross-border aid 
			deliveries. U.N. aid officials said that access has improved 
			somewhat since then.
 			U.N. aid chief Amos said this month that there had been "modest 
			progress" with Damascus, such as issuing 50 visas for international 
			staff and permitting the setting up relief hubs to store and 
			distribute supplies. But U.N. convoys from Turkey are still 
			forbidden and besieged communities are still blocked off.
 			Last week, the U.N. announced that Damascus had approved a first 
			airlift to Syria from Iraq to supply the mainly Kurdish northeast, 
			though snow has so far delayed the start of flights. 			The breakthrough followed secret talks chaired by Amos with 
			countries including Syria's allies Iran and Russia.
 			Hicks at Human Rights Watch said more should still be done to press 
			world powers to demand humanitarian access in Syria.
 			"There is always room for more vocal engagement," said Hicks. "I 
			think there is more room for explicit movement and to pressure the 
			Security Council to act on their words."
 			(Additional reporting by Dominic Evans; 
editing by Alastair 
			Macdonald and Peter Graff) 
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