The fight for healthcare in northeast Syria

It also linked pollutants to bladder cancer. The particulate matter, a major component of outdoor air pollution, "encompasses substances carcinogenic to humans", it said.

In 2022, a study by the Euphrates Center for Strategic Studies in the city of Qamishli, on the Syria-Turkey border, reported an increase in toxic emissions, leading to more air pollution and related health issues.

It revealed that, in 2021, vehicle exhausts in Hasakah province released about 890 tons of lead, with 250 tons in Qamishli and 290 tons in the city of Hasakah.

It also found that emissions of particulate matter – harmful carbon particles associated with heart attacks, strokes, and cancer – were also around 250 tonnes.

Of this, 80 tons were attributed to Qamishli and 54 tons to Hasakah, with the rest spread across other areas.

Investigators conducted atmospheric measurements during early mornings and evenings in the areas of Al-Maabadah, Girke Lege, Qamishli, Çil Axa, and Al-Jawadiyah in Hasakah province.

All are built-up areas dense with buildings, where most emissions come from vehicles, gas stations, and electricity generators.

Access to healthcare

In a 2022 report, the humanitarian relief organisation Reach reported on the health conditions in northeast Syria, focusing on healthcare accessibility for residents.

It showed that 70% of those who lived there could not access healthcare, in part because of its high costs. Most simply cannot afford it. Another reason was the lack of medical supplies or trained doctors.

Interviews with residents in Hasakah, Raqqa, and Deir ez-Zor (and surrounding areas) showed a significant prevalence of severe health issues. The list of ailments was extensive.

It included respiratory, renal, hepatic, and chest-related diseases, as well as hypertension, kidney failure, blood disorders, asthma, leishmaniasis, diabetes, cholera, prostate diseases, miscarriages in pregnant women, infertility, heart disease, and a high incidence of cancer.

Dr Danesh Haj Ibrahim, a blood tumour specialist in Qamishli, says "the estimated proportion of cancer patients in Hasakah province, in contrast to other illnesses, surpasses 9%".

Among women, breast cancer predominates, says Dr Ibrahim, while in men it is more often prostate, lung, and colon cancer. In Hasakah province, there are more than 3,500 have heart disease, while 10% of the local population have diabetes.

"Particularly concerning is the high percentage of young people experiencing Type 1 diabetes, in addition to the notable prevalence of chronic diseases," says Dr Ibrahim.

Pharmacist Abdullah Mabrouk says that in Tabqa this year, there have been 137 cancer cases. Even in an oil and gas region, that is high.

Locals say the increase can be traced back to the four-year period in which the region was ruled by Islamic State (IS) militants, whose refinement of the crude oil was crude and unrefined, to put it mildly.

Sandflies and gas flares

Moreover, Tabqa has registered 728 cases of leishmaniasis, a parasitic infection transmitted by the bite of sandflies which can be fatal if untreated.

Of those diagnosed, 94 were successfully treated, while 50 needed dialysis following kidney failure. Of these, many sought treatment in Damascus.

Alongside this, the Intensive Care Association (ICA) has highlighted a concerning trend in Manbij, where it says that "a significant number of children, both in urban and rural areas, suffer from malnutrition".

Marwan, an activist, says he has reported a rise in the number of cancer cases in Manbij to 200, attributing this to both gas flares and air contamination.

Mohammad Al-Hadi, 68, from Manbij, says he endured "acute and chronic pain as well as inflammation in the middle ear", adding that "the complications arising from the treatment resulted in me developing prostate cancer".

Marwan also reported a case where a woman developed cancer of the womb due to a medical error during a caesarean section, which led to post-surgical complications.

While exact cancer statistics for Kobani in northern Syria are not available, activist Kamal Aziz (a pseudonym) estimates the number at "over 100", adding that "the countryside is dealing with widespread leishmaniasis".

Vaccines and medications for treating leishmaniasis and preventing the spread of hepatitis are being provided with the help of organisations like Doctors Across Continents and Mentor Initiative.

The ICA also identified a "rise in disabilities" in Raqqa, particularly cerebral or multi-system atrophy, which is the damage or shrinking of nerve cells in different parts of the brain.

Lacking the basics

The region lacks basic healthcare provisions, such as mobile clinics, physiotherapy, scanning equipment, mobility aids, medical monitoring, and general health awareness in rural areas. All of this further exacerbates the problems.

The ICA thinks the number of people living with disabilities in Raqqa is now more than 10,000, alongside another 3,000 with cancer and 5,000 with diabetes.

Yet, it is not just disease and infection. Unexploded ordnance from the civil war litters the area. Doctors in northeast Syria estimate the number of amputations at 3,600. While prosthetic limbs can be found, some areas have no supply.

Researcher and journalist Firas Alawi from Deir ez-Zor listed cancer as "the most significant health crisis afflicting the province", saying cases now topped 1,000. 

Leishmaniasis has also hit the countryside east of Deir ez-Zor, including Al-Shaitat, Hajin, and the towns of Ash-Sha'Fah, Al-Susah, and Baghuz. "The number of infections in these areas is approaching 400. The majority being children."

Dr Bakr Al-Sayed Ahbash from As Sawa in western Deir ez-Zor listed the prevalence of smoking in young children as a cause, adding that cholera outbreaks came from water pollution and inadequate sterilisation.

"Additionally, there is a widespread occurrence of chickenpox lacking immediate treatment, along with a notable number of cases involving lung and kidney cancer, as well as leukaemia," said Ahbash.

Damascus and Erbil

Six-year-old Joud's uncle, the academic Farid Sa'adoun, shared the challenges and costs of cancer treatment in Syria.

"Treatments involving radiation, chemotherapy, and medications used to be provided free of charge in Damascus," he said.

"However, the provision of free services ceased, and the availability of doses decreased. I had to purchase them in dollars, ranging from $200 to $850, depending on the type and cancer.

"With the absence of free treatment and treatment centres, only those who are well-off can bear the costs of medicine. The poor cannot afford treatment for cancer. The cost is prohibitive."

Fahd Suleiman, accompanying a cancer patient, said simply getting to Damascus was expensive, and that is before accommodation and expenses are considered.

He said the alternative, of travelling to Erbil for treatment, was a little less expensive "but requires approvals and adhering to specific procedures".

Sources from the Faysh Khabur, on the Iraqi-Kurdish side of the Syria-Iraq border, say "thousands" of Syrians with heart disease, cancer, eye surgery, and kidney problems enter the Kurdistan Region of Iraq every year for treatment.

At Al-Bairouni Hospital, which specialises in cancer treatment, they said there are two new cancer cases from north-east Syria every day or 720 patients annually.

In 2022, a total of 5,830 cases of thalassaemia (a blood disorder) were reported across Syria, and nearly a quarter originated from the northeast.

The ICA showed that "60% of all cancer cases in Syria are concentrated in north-eastern Syria".

Unrefined refinement

Several doctors we encountered felt that the health situation was deteriorating, citing epidemics and drug-resistant diseases.

Some of these diseases had almost been eradicated in the region but have surged back due to pollution from the emissions from toxic gases and primitive oil refining.

Basic refining processes mean that products retain carcinogens that dissolve in diesel and petrol before being released into the air during combustion, particularly from the incomplete combustion of fuel and generator smoke.

This leads to the release of lead and other toxic substances, as well as naphthalene gas, which acts on the blood, kidneys, and liver, causing cancer.

We heard that the region lacked a designated facility for managing the by-products and waste from oil refining, resulting in its haphazard disposal, including by mixing it with water.

Over the years, disposing of oil refining waste into rivers and canals has contaminated the soil with substances like arsenic, lead, and mercury. These, in turn, are absorbed by plants and vegetables.

Food, water, and bodies

Asked why these diseases were proliferating, one doctor listed "the indiscriminate use of medications, the consumption of unhealthy and unsanitary food, the use of plastic for storing food and water, and the increase in swamp areas due to the limited water supply from Turkey, facilitating the spread of insects and disease".

They added that "the drop in water levels in the Euphrates River, its contamination, and the proliferation of rubbish on the roads, coupled with the absence of irrigation water, have transformed the river into a swamp, creating an environment conducive to the breeding of sandflies". 

Others list the absence of health monitoring on food, particularly imported meat and vegetables from neighbouring countries, and the lack of awareness regarding hormone levels and their influence on environmental and food pollution. 

Compounding the problems, we heard, is the "inadequate infrastructure of the health sector, the lack of a proper sewage system in certain villages, and diseases from decomposing bodies in mass graves around Baghouz".

These graves contain the remains of thousands of Syrians killed and hastily buried by IS fighters, we were told. Despite their partial removal, many remain. They "contribute to the proliferation of skin and respiratory diseases", one said.

Easy ailments only

Hasakah, with its nine hospitals and 50 clinics, is committed by the Autonomous Administration to offer free or partially free healthcare services at competitive rates.

However, activists say these facilities mainly offer essential services like first aid and face a medication shortage.

Caesareans are not available in the province. It also doesn't have a dedicated diabetes treatment centre, early breast cancer detection equipment, or a decent kidney dialysis centre.

While the Autonomous Administration's Heart and Eye Hospital conducts surgery cheaper than in private hospitals, its equipment is second-rate.

We hear that some doctors refer patients to their private healthcare centres, clinics or hospitals, of which 38 are across Hasakah province.

Drug prices in hospital pharmacies are unregulated, and the costs associated with surgery and overnight stays, especially caesarean sections, vary greatly.

Likewise, fees for medical examinations – up to $5 – add to the burden on residents.

For more complex conditions like cancer and heart diseases, patients often prefer to seek diagnosis and treatment in Erbil or Damascus, attracted by the doctors' expertise and modern medical equipment available there.

In Manbij, those without money can attend Al-Furat National Hospital and five free clinics, but treatments are limited to emergencies, certain mild diseases, and the administration of free childhood vaccinations.

Despite there being ten private hospitals, their scope of services is restricted to paediatrics (the treatment of children), minor fractures, and caesarean sections, often at hefty prices.

Even routine surgery, such as having an appendix out, can cost hundreds of dollars. For the management of chronic diseases and trauma injuries, those on stretchers or respirators must look elsewhere.

Public vs private

Pharmacist Abdullah Mabrouk from Al Tabqah says his city's national hospital can conduct mammograms for the early diagnosis of breast cancer. Around 13 medical centres dot the city and surrounding countryside, offering some services.

In Kobani/Ain al-Arab, activist Kamal Aziz explains that the city has a single government hospital, in addition to the Igor Hospital specialising in women's diseases, the private Al-Amal Hospital, and several clinics.

Everyone there confirms the scarcity of medicines, medical equipment, specialised staff, and essential services necessary for patient care, limiting the role of these medical centres to address simple and minor illnesses.

According to the ICA, three hospitals are affiliated with the Autonomous Administration in Raqqa. Still, the ten clinics – often in rural areas - are confined to examinations, emergency cases, and medication dispensing.

The ICA describes treatment and accommodation costs in private hospitals for procedures such as cardiac catheterisation as "exorbitant".

It added that the current state of health services in Raqqa was "inadequate for the population density it bears", due in part to internal displacement from other areas.

Service quality has deteriorated due to corruption and nepotism in the public health sector, and a lack of oversight. Still, owing to the exorbitant prices charged by private hospitals, many have no choice.

As if to demonstrate the point, the only free CT scanner in the region is not working, we are told. The Health Directorate is yet to rectify the situation.

Some eradicated diseases such as malaria and tuberculosis have also made an unwelcome reappearance here, we are told, as have a plethora of skin diseases, which medics attribute to water pollution.

No health shield

Dr Abdul Rahman Ali from Deir ez-Zor says there are nine public hospitals here, with five receiving support from external organisations and 13 public clinics, seven of which benefit from outside help. There are also 21 private hospitals.

Firas Allawi describes a postcode lottery. In some areas, often the poorest, there are few doctors trained in specialisms.

"Relatively speaking, it is better in areas controlled by the Autonomous Administration, but there is still a shortage of equipment, medical tools, high-quality medicines, and vaccines." 

Dr Bakr Al-Sayed says the province lacks treatment for eye diseases, while paediatric surgery is limited. He also describes a shortage of ambulances and inadequate supplies of oxygen.

According to Joud's uncle Farid, "there is no healthcare system to shield people from these diseases in the absence of vaccines and immunisation".

Pollution triggers numerous immune-related diseases, he says and intensifies their impact. "Cancer tends to flourish in the presence of weakened immunity.

"In the past, state-owned companies treated harmful gas and oil waste. Nowadays, no one treats the source of these cancer-causing emissions."

Knowing the need

Everyone involved in the medical sector recognises the need for trained staff, specialist treatment centres, and hospitals dedicated to the diagnostic and pathological analysis of severe diseases.

This has to include facilities for cancer treatment offering chemotherapy, as well as treatments for chronic conditions such as pulmonary fibrosis and heart disease, including cardiac catheterisation and heart surgery.

The wish list goes on. Conditions like asthma, hypertension, kidney failure, diabetes, and leishmaniasis need proper treatment, including hormonal medical tests and adequate supplies of insulin.

Free medication for all this is imperative, they say. If it is unavailable, most will feel they must travel to Damascus, shouldering the high treatment costs.

Health in the camps

Dr Khalil Khalo, a pharmacist at the Al-Talaae camp Sere Kanye in Hasakah, addresses the health situation in refugee camps.

"Most camps exhibit similarities in terms of epidemics and prevalent diseases, particularly leishmaniasis and scabies," he says.

"The surge in medicine prices from Damascus, up by 100%, plus a 28% charge for shipping, just exacerbates the situation. The Kurdish Red Crescent runs some clinics to address the need, but its falls short of meeting such high demand."

Dr Danesh says Syrians' cancer medication is "sourced from Turkey and India" and are "highly expensive, particularly the immunotherapy variant". He adds that they are not always readily available.

"Most patients seek treatment in hospitals in Damascus, especially for children with blood diseases who receive free treatment there. At present, the cancer treatment centre in Qamishli is primarily limited to serums and lacks medication."

The Kurdish Red Crescent agrees, adding that it works "with international organisations to provide free medical assistance to cancer patients" where it can.

The Red Crescent says it "provides services, care, medications, and physical treatments, as well as the installation of prosthetics", adding that it has treated 1.5 million patients in 54 medical points.

How it came to this

Healthcare in the north-east of Syria is in desperate need on an injection of skill, knowledge, equipment, money, oversight, coordination, manpower, and medicine.

Before Syria's civil war, access to and quality of its medical sector was improving. From 1970 to 2009, life expectancy rose from 56 to 73 years, while infant mortality dropped from 132 (per 1,000 live births) to just under 18.

Then came chaos and war. Tens of thousands were killed, and hundreds of thousands were displaced. Many fled abroad, never to return. Basics like sanitation and water supply can no longer be relied upon.

Meanwhile, little Joud continues his battle with leukaemia. His uncle, Farid, wonders where the money will come from — a fitting snapshot in the collective fight for healthcare in Syria.