“Among challenges in past months is the general security situation, medicine shortages, and lack of personal protective equipment for our staff", the doctor says as he examines Warda’s foot.

We’re in a primary health care centre in the village of Zardana in Idleb governorate, a short distance from the Turkish border. The centre is one of nine centres in northwest Syria that are part of a WHO project on noncommunicable diseases (NCDs), aiming to provide a package of treatment protocols and operational procedures. The staff have been trained in screening and early detection of chronic disease.

“What’s bothering you is a complication of your diabetes”, the doctor says to Warda, a 60-year old mother of five children that have all moved elsewhere and have their own families by now.

“I know I’ve neglected my own health and that I haven’t been able to take proper care of myself. These days, I live alone and there is no one to take care of me. I’ve had this tingling feeling in my foot and it started to get more and more painful and even turned blue. Eventually I decided to go to the clinic out of fear of losing my foot. This time I’ll do as the doctor tells me”.

When Warda visited the centre for the first time, and met up with the NCD team, she was signed up in their registry after a proper examination, tests and a consultation. With a specific card she’s been given, she now gets free medication.

“At times, when the medicines haven’t been available at the health centre pharmacy, I’ve had to buy my drugs from a private pharmacy”, she says.

Like millions of other people in northwest Syria, Warda has been displaced by the fighting. The majority of those that have had to leave their homes so seek safety from the violence, are women and children.

"I once lived a stable life in in the city of Atareb in Aleppo governorate, but after my husband passed away, my situation and well-being got worse. And having to live in a camp, after the bombing of my city, my condition deteriorated further", Warda explains.

After Warda started to pay regular visits to the NCD team in the health centre, her foot has started to heal. “I just hope things will become more stable so I can return home to Atareb”, Warda remarks.

WHO’s support to the nongovernmental organization SRD (Syria Relief and Development) who runs the primary health care centre that’s part of the NCD project is made possible through funding from OCHA (The UN Office for the Coordination of Humanitarian Affairs) and CERF (Central Emergency Response Fund).

“After my husband's death eight years ago, I began feeling discomfort and constant fatigue”.

The widow Umm Abdullah, 55, is one of between two and three million people that are displaced due to the fighting in northwest Syria; refugees within their own borders. Her husband’s death, one year into a conflict that’s been named the most complex humanitarian crisis of our times, left Umm Abdullah as the sole provider for her son, who at the time was only eight years old.

“We’ve had to flee several times, we’ve been on the move between western Aleppo and northern Idleb for years. And after the recent escalation in fighting, we ended up here, in Kafr Safra”. The most recent hostilities, that displaced nearly 1 million people, started in December 2019 and came to a halt when Turkey and Russia agreed upon a ceasefire in March 2020.

Before the conflict started in 2011, the village of Kafr Safra, part of the Afrin district in Aleppo governorate, had a population of only a couple of thousand. Since then, its population has steadily grown and it is now home to dozens and dozens of Syrians whose fate is the same as Umm Abdullah and her son.

“We’ve gone through hardship”, she says.

Being internally displaced – without a roof over your head and with your few remaining belongings on your back, if you’re that lucky – is not easy. And suffering from a chronic health condition is an added challenge, and can in many cases be life-threatening, when access to medical assistance and drugs can’t be relied on or is simply unavailable.

“What’s been most challenging on the run is finding health centres that cater to those with chronic diseases. Finding the right drugs has been difficult, let alone being able to afford them. That’s been a heavy burden”.

While most internally displaced persons (IDPs) use most of their waking hours trying to stay away from danger, reading the environment, avoiding circumstances where things could possibly escalate, trying to stay warm, safe, fed – staying alive simply – the challenges for the internally displaced that have underlying diseases and suffer from a chronic condition, take on a different dimension. That means that every new displacement has required of Umm Abdullah to locate and seek health services, simply to be safe.

“The moment we reached Kafr Safra, I started asking around about the nearest health centre, I wasn’t well. You can therefore imagine how happy I was learning there is one in town. It’s the only one in this area, serving 10 villages.”

The fact that more than half of Syrian health workers have left the country or lost their lives during the conflict, means that those that remain have taken on a double workload, if not more, with limited resources. One of them is Dr Ali and it was he who examined Umm Abdullah on her first day in Kafr Safra.

“Hypertension and diabetes, the two conditions that plague Umm Abduallah, actually require routine, constant monitoring and regular medication“, explained Dr Ali, as he prescribed the drugs and booked the next appointment at centre.

“I’m better now, I see the doctor regularly and the drugs are free of charge. I still dream of returning home though; of raising my son there and being able to visit relatives“.

“It’s only recently I discovered I had only one kidney. My immediate thought was how I’d be able to provide for my family now that I’d need transport for regular hospital visits for treatment.”

Mohamad*, 34, is father to two girls and a boy. He’s also the breadwinner of a family that’s been displaced several times in the last six years, due to fighting in northwest Syria. As of today, there is a ceasefire in place and Mohamad, his wife and children live in the village of Sheikh Yousef in Idleb governorate, some 30 kilometres from the hospital, close to the border with Turkey.

A couple of months ago, Mohamad was at work when he suddenly felt excruciating pain under his left ribcage. He was taken to hospital where examination revealed he’d been born with only one kidney. One in 750–1,000 people have the condition. Most lead normal lives, despite a slight risk of decreased kidney function or high blood pressure later in life, which is why regular medical check-ups are advised.

“I never had any health problems. Now, however, I’ve been told I can’t do physically hard labour and I need to go to the hospital every now and then”, Mohamad says. Indeed, it was at Kafr Takharim hospital where he learnt about WHO’s referral system and the transport it provides through the nongovernmental orgnization SRD (Syria Relief and Development), free of charge.

With only half of health facilities in northwest Syria functioning, what makes it possible for a fragmented health infrastructure to cope with the health needs of four million people, of which the majority are internally displaced like Mohamad, is a referral system put in place by WHO.

Attacks on health care, a hallmark of the conflict in Syria, have brought the number of functioning health facilities further down and deprived civilians of basic access to medical care. Mass displacement has also forced some health responders to suspend their services, while some have been able to relocate and cater to the displaced in camps or settlements.

The total number of facilities that are still running in Idleb and Aleppo is close to 300, while the pre-war figure was close to 600. This figure includes primary and secondary health facilities, specialized health centres, labortories and ambulances. And between them, there is a tight network, operated by dozens of health partners like the SRD, that make sure patients get the medical treatment they need despite the many challenges.

“My life has changed. The condition does restrict me and I’ve got financial concerns. But I’m also relieved because the referrals save me money and effort. And I have full confidence that I’ll manage to find a job that doesn’t require hard physical work, and at the same time, take care of my family.”

*Not his real name.