Eid Hanani has not been affected by the bombs, the snipers or the shelling that have engulfed many parts of Syria.
He only barely escaped death, but his was a threat of a different kind.
In July, he was diagnosed with cancer of the bladder. But the only cancer hospital in the capital Damascus was out of serum injections used for treatment.
The nearly two-year conflict in Syria has taken tens of thousands of lives, destroyed entire neighbourhoods and sent hundreds of thousands of people fleeing. But more quietly, it has also eaten away at the country’s healthcare system.
Pharmaceutical factories, which used to produce more than 90 percent of the country’s drug needs, are down to one third of their former production, according to Elizabeth Hoff, the representative of the World Health Organization (WHO) in Syria.
Many have been destroyed or damaged in the fighting - sometimes directly targeted by the opposition. The northern city of Aleppo, one of the worst affected by the conflict, was home to most of the factories. Other factories are struggling to import raw materials due to sanctions imposed on Syria by Western countries. Insecure routes have also affected supply lines.
On the black market, Hanani was able to find, but just barely, an alternative to the cancer serum, smuggled in from Lebanon. The dose costs him 5,000 Syrian pounds (US$70) a month, half the monthly salary of his son, the family’s sole breadwinner.
“Without it, the pain is extreme, I don’t sleep, and eventually, I would die,” Hanani told IRIN, a small cloth tied around his neck to cover the hole in his throat - a legacy of another bout of cancer he overcame four years ago. His dirty fingernails hold a machine against his throat to help him speak. “My life is in God’s hands,” he said with a smile, exposing missing teeth.
The shortage of medicines is just one part of an exploding healthcare crisis in Syria, as hospitals run out of space and supplies, health workers struggle to get to work, patients lose access to health facilities, and medicines shoot up in price.
Shortages in pharmacies
Many pharmacies, even in Damascus, are struggling to keep up with the demand, their shelves increasingly empty; specific brands unavailable altogether. Amid shortages as high as 40 percent, some pharmacies have limited the amount of medicine they give each customer.
“Just give me a few more boxes - I beg you,” one customer recently pleaded at a pharmacy in an upper-middle class neighbourhood of Damascus. “I need this medicine and we have no pharmacy in Harasta.”
Two pharmacies used to service Harasta, a suburb of Damascus that has seen heavy fighting in recent months. The first was looted amid the chaos; the owner of the second packed his things and left when the government started shelling the area, the Harasta resident said.
To get the medicine she needs daily, she walks 20 minutes to an area still served by public transport, and rides into the capital.
Other highlights from the WHO report
- Of 520 ambulances, 304 have been damaged or affected
- Oxytocin, routinely provided to all mothers during labour to prevent haemorrhage, is no longer available in maternity wards in affected areas
- Across the country, local pharmacies are increasingly unable to provide regular medicines like painkillers and insulin
- The national vaccination coverage for the first quarter of 2012 dropped from 95 to 80 percent
- There is only one supplier of chlorine gas and sodium chloride, needed to purify water, left in the country
- More women want to breastfeed their babies because they cannot afford infant formula
As she begs for more boxes, another customer calls into the pharmacy looking for Vitamin B complex. Normally, the pharmacy carries 10 different brands, but on this day, none remain.
“I have to turn away many customers,” says the pharmacist. “Often we can offer the patient an alternative to the brand they usually take, but sometimes, we have nothing.”
Pharmacies have tried to make up for the gap in local production by bringing in medicines from outside, but they have only managed to do so in limited and unorganized ways, and at a higher cost that many Syrians can no longer afford. (International medicines are not always covered by Syrian insurance companies).
According to Hoff, insulin is no longer available in some of the areas affected by the conflict. Prior to the conflict, she said, 40,000 diabetic children in the country depended on insulin pens that are no longer available through public health centres. They now have to resort to a method that is more painful and harder to use.
Those medicines that are available have also risen in price, and amid skyrocketing unemployment and rising food prices, many Syrians - especially those displaced from their homes by the violence - are struggling to afford their usual medication.
Nawras Sammour, a Jesuit priest in Damascus who has been helping people affected by the Syrian crisis, has been approached by more than 600 people who can no longer afford their medicines and treatments for chronic conditions, like diabetes and hypertension.
“Displaced people have nothing. They have no money to buy,” Sammour said. “We help those we can. But those who have cancer, for example, we have nothing to offer them. We just can’t afford it.”
Other agencies which offer medical services, like the International Medical Corps (IMC), are also affected by the shortages. IMC normally procures 66 drugs for its clinics and mobile teams, but more than 40 percent of them are no longer available in the country, the organization’s director in Syria, Natalia Valeeva, told IRIN. The NGO is planning to order medicines from abroad, but may struggle with higher costs and delays due to shipping and customs clearances. Others have complained that some countries are reluctant to ship to Syria for fear of violating sanctions.
Access to health care
The shortage and price of medicines are just the tip of the iceberg. Fighting has partly or completely destroyed half the country’s 88 public hospitals, with 23 of them not functioning at all. Of 1919 health centres, 186 have also been damaged, with 106 of them not functional.
As a result, “the hospitals and health centres that are operating are overwhelmed with patients,” says a recent report by WHO.
One maternity hospital in Damascus has limited patients to a 6-8 hour stay to be able to accommodate more patients; at the pediatric ward of the national hospital in the northern governorate of Al Raqqa, children are sleeping two to a bed, the report said.
Some patients cannot get to the hospital at all.
Amoon el-Yousif, 60, used to treat her high blood pressure - one risk factor of diabetes - by taking a pill daily. When her hometown of Hama was caught up in the fighting, she stopped the pills, unable to reach the pharmacy under heavy shelling. Two months later, unchecked blood pressure worsened her diabetes to the point she developed gangrene (loss of blood supply) in her toe. As it rotted away, she had to be rushed by ambulance 200km south for an emergency amputation in Damascus. Now she needs insulin she cannot afford - and may not be able to find - to treat the diabetes. Treated improperly, the disease can be fatal.
Hoff said she met one nine-year-old boy from Dera’a who travels to Damascus twice a month across dangerous roads to get the blood transfusions he needs to live.
Those who do get to hospital may not always find the care they need.
In Damascus, Aleppo and Homs, 70 percent of healthcare workers live in rural areas and have trouble getting to work because of snipers on the road, delays at checkpoints, or insecurity.
Doctors are increasingly leaving the country. All of the country’s nine psychiatrists and more than half the doctors in Homs have left, the WHO report said.
“The number of casualties is on the rise,” said Rabab Al-Rifai, communications coordinator of the International Committee of the Red Cross (ICRC) in Syria. “Every day, tens of people are dying because of the armed confrontations, and an increasing number of injured are succumbing to their wounds, unable to receive medical care because of insecurity and lack of medical material.”
UN appeal underfunded
The UN appeal for humanitarian funding, revised in September, included more than $53 million in health-related projects for 2012 - but remains less than one third funded.
This has left people making desperate choices. As the blood bank runs dry, people are turning to family and friends for blood transfusions.
Syrians are also reportedly travelling to Lebanon; registering as refugees in order to get medical care they cannot access at home; and then returning to Syria.
Fearing a lack of timely access to healthcare, women are also increasingly opting for Caesarean sections, Hoff said. While abortions are illegal in Syria, doctors have told her that an increasing number of women come to the hospital with incomplete abortions, haven taken pills from pharmacies that do not work completely.
“They don’t see how they are going to face a pregnancy because of all the difficulties, and another child to cater for when they can hardly cater for those they have.”
Filling the gaps
As the government loses its ability to provide healthcare, others are stepping in to fill the gap.
Some private hospitals, like Al-Bir hospital in Homs, are offering treatment free of charge to those who can no longer afford it.
Despite damaged infrastructure and insecurity, the Ministry of Health, the UN Children’s Fund (UNICEF), WHO and their partners began a vaccination campaign late last month, aiming to reach all of the country’s 2.5 million children, many of whom have not received routine, but potentially life-saving, immunization against measles and/or polio for months because of the conflict.
They used mosques, churches, kindergartens, TV channels and text messages to inform people of the campaign, and perhaps surprisingly, hundreds of thousands of children have already been vaccinated despite the challenges, with 6,000 ministry health workers in the field.
ICRC and WHO are providing some hospitals with trauma surgery supplies, including surgical items, anesthesia drugs, operating tables, chest drains, intravenous fluids, dressing material or ventilators, depending on the needs.
ICRC and IMC are also providing medicine and equipment to the Syrian Arab Red Crescent (SARC), which is offering primary healthcare services to displaced people.
IMC has provided health and psychosocial services to more than 40,000 Syrians, through its clinics and in five schools of displaced people.
WHO and ICRC are both working to improve the quality and testing of water in affected areas, helping to provide clean water to millions of people in Aleppo, Damascus and surroundings, Homs and elsewhere.
Many national NGOs, such as Al Afya Fund, the Syrian Agency for Health Promotion Activities and the Syrian Family Planning Association, are complementing government and private sector efforts. For example, mobile health teams managed by the Syrian Association for Health Promotion and Development are also providing basic health services in five governorates.
WHO has supplied blood safety kits to the National Blood Bank.
In conflict areas, SARC medical teams are evacuating and treating injured people who cannot access health facilities.
Médecins sans Frontières is providing emergency medical treatment, including surgery, in areas controlled by rebels in northern Syria.
Where the Ministry of Health cannot access patients in areas controlled by the opposition, WHO is increasing the delivery of medicines and supplies through local NGOs. So far, it has provided more than one million treatments in Aleppo, Damascus, Rural Damascus, Dera’a, Homs, Al Raqqa, Deir-ez-Zor, Idlib, Tartous and Quneitra governorates.
But even so, “we cannot deliver fast enough and we don’t have enough funding to take bigger support efforts,” Elizabeth Hoff, WHO representative in Syria, said.