© Photograph: Heba Aly/IRINShelling in Amoon el-Yousif's native city of Hama made it impossible for her to access needed medication from the pharmacy.
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 faced 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 the serum injections used for treatment.
The nearly two-year conflict in Syria has claimed tens of thousands of lives, destroyed entire neighbourhoods and sent hundreds of thousands of people fleeing. More quietly, however, it has eaten away at the country's healthcare system. Pharmaceutical factories, which used to produce more than 90% 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 Organisation (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, 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 affected supply lines.
On the black market, Hanani was able to find an alternative to the cancer serum, smuggled in from Lebanon. The dose costs him 5,000 Syrian pounds (£43) 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," said Hanani, who wore 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 told IRIN with a smile, exposing missing teeth.
The shortage of medicines is just one part of the 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 demand; their shelves are empty and specific brands are unavailable. Amid shortages as high as 40%, 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 experienced heavy fighting in recent months. The first was looted amid the chaos; the owner of the second left when the government started shelling the area, the Harasta resident said.
To get the medicine she needs daily, she walks for 20 minutes to an area still served by public transport, and rides into the capital. 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," said 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 unorganised 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 areas. Previously, she said, 40,000 diabetic children in the country depended on insulin pens that are no longer available through public health centres. Now they must resort to a method that is more painful and harder to use.
Those medicines that are available have risen in price, and amid spiralling unemployment and rising food prices, many Syrians - especially those displaced by the violence - are struggling to afford their usual medication.
Nawras Sammour, a Jesuit priest in Damascus, has been approached by more than 600 people who can no longer afford their medicines and treatments for chronic conditions, such as diabetes and hypertension. "Displaced people have nothing. They have no money to buy," he 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 that offer medical services, like the International Medical Corps (IMC), are also affected by the shortages. Normally, IMC procures 66 drugs for its clinics and mobile teams, but more than 40% of them are no longer available in the country, the organisation'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 healthcare
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 1,919 health centres, 186 have been damaged, and 106 are no longer functional. As a result, "the hospitals and health centres that are operating are overwhelmed with patients", according to a recent report by the WHO.
One maternity hospital in Damascus has limited patients to a six- to eight-hour stay to accommodate more patients; at the paediatric ward of the national hospital in the northern governorate of al-Raqqa, children are sleeping two to a bed, the report said. But 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 where she developed gangrene in her toe. She had to be rushed by ambulance 200km (124 miles) 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 don't always find the care they need.
In Damascus, Aleppo and Homs, 70% 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 leaving the country. 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 co-ordinator of the International Committee of the Red Cross (ICRC) in Syria. "Every day, dozens 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 $53m 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 to get medical care they cannot access at home; then returning to Syria.
Fearing a lack of timely access to healthcare, women are 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, having 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."
"The nearly two-year conflict in Syria has claimed tens of thousands of lives, destroyed entire neighbourhoods and sent hundreds of thousands of people fleeing."