Marah al-Khalaf, a Syrian child barely over the age of 10, stands alongside her father Asa’ad, 35, in front of the main gate of the Bab AlHawa Border Crossing for the second consecutive week.

Despite putting in several applications to gain entry, Asa’ad’s attempts to take his cancer-afflicted daughter into Turkish territory in order to receive the necessary treatment have failed.

Asa’ad and his daughter were able to cross the border for free healthcare months ago, under authorization from the Turkish government. According to figures issued by authorities from the Syrian crossing, more than 500 patients entered Turkey to receive treatment last February.

That was until the spread of the Coronavirus (COVID-19) accelerated, prompting the Turkish government to cut off their lifeline in mid March, just three days after Ankara confirmed its first case and two weeks before Damascus declared the appearance of its first confirmed cases.

Doctors in the Idlib governorate have stated that since mid-March only a handful of high-risk emergency cases were allowed entry into Turkey, amidst an increasing number of cases in both countries. Patients suffering from cancer and other chronic illnesses are not among them.

For the time being, Marah, along with hundreds of other patients, remains stranded and unable to receive life-saving treatment.

As Asa’ad carries his ailing child on his forearm, she rests her head on his shoulder to whisper unintelligible words. His eyes fill with tears as he says, “She has jaw cancer and as the tumor grows, her pain grows with it. These days she cannot even sleep from the agonizing pain, despite taking all types of painkillers. My daughter needs treatment. Please, Lord, don't forsake us.”

Due to lack of treatment in north Syria, doctors have unanimously agreed on the necessity for Marah to head to Turkey for medical care, says the family, but she remains until this day stranded at the border.

With the continued spread of the Coronavirus and the accompanying restrictions against Syrians along the Syrian-Turkish border, this investigation explores the plight of those suffering from cancer and other chronic diseases as they await their turn to enter Turkey.

400 Cancer Patients Await Reprieve

The Idlib Health Directorate describes the scale of the suffering cancer patients are facing in northern Syria, amidst increasingly poor medical care in the region. Issues hindering access to treatment include acute shortages of medicine, equipment, and working medical facilities, not to mention the rising costs of the few available treatment drugs left in the area. Such difficulties prompted patients to enter Turkey through the Bab AlHawa Border Crossing, after obtaining a medical referral from the health directorate.

On the 13th of March, the Bab AlHawa Border Crossing announced its closure towards ‘cold case’ patients – the Arabic term that encompasses chronic illness such as cancer and heart disease – and travellers. The crossing remained closed to cancer patients until the first of June, after which authorities allowed the entry of only 5 patients a day for treatment in Turkey, following coordination between the crossing administration and Turkish authorities.

Barely a week had passed before the border pass was once again closed off, an act prompted by a number of reported Coronavirus cases in north Syria. The crossing was reopened later on, under strict requirements for patients to adhere to safety measures against the virus.

According to Doctor Mohammad al-Salam working at Bab AlHawa Hospital, the repeated closure led to a rise in critical cases among ‘cold case’ patients.

Mazen Alloush, the director of the Office of Public Relations and Information at the crossing, has revealed that over 400 cancer patients have been waiting their turn to enter Turkey for weeks, aside from the dozens that haven’t applied in the first place. Alloush also stressed that the majority of patients need entry as soon as possible due to mounting critical cases.

As a result of recent restrictions, the medical state of Maram al-Sayyed, 45, is in rapid deterioration. This is the third consecutive time she has not been allowed to cross into Turkey for treatment, even though her 8-month-old Leukemia condition has reached well into its advanced stages.

She takes several minutes to gather her strength to speak, “I am exhausted; the disease has been eating away at my body for some time, and I am getting worse. I cannot go to government-held hospitals where people are getting arrested, while Turkey here closes the crossing. What do I do as this cancer ravages my body?”

Maram is receiving pain medication as well as up to two blood transfusions per day at the Idlib Central Hospital, to no avail.

It is up to hospitals and health centers in the liberated north to work with aid agencies to secure medication for the time being, until the rest of the cases are transferred to Turkey for the appropriate treatment.

With spread of COVID-19, the Turkish government cut off the lifeline to Syrian cancer patients seeking treatment by mid March; Three days after Ankara confirmed its first case and two weeks before Damascus declared the appearance of its first cases.

“The man’s attempts to enter his cancer-afflicted daughter into Turkish territory to receive the necessary treatment have yielded no results despite putting in several applications to gain entry… For the time being, Marah, along with hundreds of other patients, remains stranded and unable to receive life-saving treatment.”

Idlib opposition Health Director Dr. Monzer Khalil describes the damages done to health facilities in northwest Syria by stating, “The regime has targeted more than 75 medical centers from April 2019 until today. Government forces advancing on and taking areas from the northern rural Hamah to the Southern rural Idlib, have caused the facilities’ closure.” He went on to point out, “Acute shortages of specialized medical staff also cannot match patient numbers. There is also a shortage in medical equipment such as MRIs, CT scans, and many others.”

Delay Leads to Death

Weeks ago, Yousef Barbour, 22, passed away due to delays in entering Turkey to receive treatment, despite the repeated appeals of his mother. The young man had needed a bone marrow transplant.

Such amounts of increased suffering prompted Syrian humanitarian actors to call on Turkish authorities to find some way to admit critical cases for medical care in their hospitals. However, the crossing remains closed.

A 3-year lung cancer patient, Salem al-Ahmad, 50, had been lucky enough to enter Turkish hospitals for treatment earlier. He says, “Things were much simpler then; Turkish doctors at the border crossing would not reject cancer patients, who were considered priority cases. What used to be over 100 cases admitted per day became just five cases, and this led to the deprivation of many patients’ early treatment.”

Mazen al-Saud, a professor at the Faculty of Medicine at the Free Aleppo University and former director of Doctors Without Borders hospital in Ma’arat al-Nu’man, comments, “The lack of radiotherapy in the Idlib Governorate is a major obstacle for cancer patients there, since chemotherapy is often ineffective, with the tumor reappearing more aggressively in other areas in the body.”

He adds that the number of cancer patients in the Idlib region has multiplied by 10 percent than in previous years, specifically breast cancer for women and lung, colon, and stomach cancer for men.

The WHO stated in an earlier report that cancer in Syria is 3rd among the 10 main fatal illnesses, with cases expected to further rise amidst damaged hospitals left unavailable for use.

According to the report, around 25,000 cancer patients require treatment every year, including a staggering 2,500 below the age of 15 years suffering from leukemia and lymphoma.

Within the camps of Tal Alkarama in the Harem District north of Syria, Monaf Mohammad al-Saleh, 11, suffers from speech impairment, an amputation in his left leg, and deformed fingers, along with a hazardous lack of sensation.

Monaf was hit by rocket shrapnel from Russian air raids as he played outside his home in Sarha in eastern Hama. Doctors say his leg suffered from a bacterial infection that reached the bone and left dead tissue in its wake.

His father says, “We couldn't find him treatment. In addition to the financial situation and lack of good hospitals, he hasn’t been able to receive the proper treatment yet. He needs to enter Turkey as soon as possible. Sadly, the closed border due to the Coronavirus is endangering his life, keeping in mind that the chances of him recovering and benefiting from his treatment lessens as time passes.”

After Syrian government forces entered the village of Sarha, Monaf’s family fled to camps in northern rural Idlib. Doctors were forced to amputate the infected leg after the boy’s condition deteriorated due to lack of proper health requirements. He later got an infection on his tongue from unknown causes.

The father recounts, “It became hard for him to speak and talk. He also lost sensation in his body and couldn't feel heat or cold or fire.”

Weapons Residues

Among the reasons for the recent spike in cancer cases in Syria, Dr. Hind, a research oncologist at the Idlib province, lists three: there has been a spread of kidney infections and liver diseases that - when left untreated - can become precursors to cancer; poor food quality and the consumption of expired goods; as well as the drastic “loss of hospitals, medical equipment and personnel that impedes routine checkups and, thus, lowers chances for early detection and diagnosis.”

The rise in cancer rates was a foreseen consequence in liberated areas, however, where toxic chemicals, heavy weaponry, rampant destruction, and environmental pollution are widespread remnants of the war.

 His eyes fill with tears as he says, “She has jaw cancer and as the tumor grows, her pain grows with it".

To that extent, Dr. Ayham al-Ahmad posits the higher cancers rates in liberated areas as a result of the heavy presence of toxic and oxidized weapons, as well as the overall lack of environmental hygiene and cleanliness in these areas - all of which encourage viral and bacterial infections that act as catalysts for the development of cancerous tumors.

Moreover, the entirety of northwest Syria suffers a shortage of cancer treatment medications, compelling patients to make the journey south towards regime-controlled areas, where treatment is more available. With its gruesome roads, many checkpoints, and costly travel expenses, however, the lengthy trips are exhaustive to both the patients’ health and their pockets.

Faisal, 43, lives with his wife and nine children in a tent at one of the many makeshift camps sprung along the Syrian-Turkish border. Six months ago, he was diagnosed with a cancerous brain tumor and has since not been able to get treated owing to the dilapidation of medical facilities in the Idlib province and the unfeasibility of obtaining medicine from Turkey after the shutdown of its borders.

Faisal outright refuses to go to Damascus, where he is adamant that regime forces detained two of his brothers for aiding the Syrian revolution. According to him, one of his brothers was murdered and the other disappeared not long after.

“The Turkish medical team refused to let her pass despite all our appeals, saying she is a non-emergency ‘cold case’... The delay in her treatment can lead to the growth and spread of the tumor, deteriorating her already worsening state.”

As his health deteriorated with the growth of the brain tumor, the imperative to find medication grew more urgent, and Faisal turned to charity-based pharmacies for help. Alas, to no avail.

The Turkish medical team refused to let her pass despite all our appeals, saying she is a non-emergency ‘cold case’... The delay in her treatment can lead to the growth and spread of the tumor, deteriorating her already worsening state

A doctor working at the Syrian American Medical Society (SAMS) office in the Turkish city of Gaziantep notes, “The SAMS center in Idlib is the only place offering treatment for breast cancer, lymphatic cancer and colon cancer in the entire province. The treatments are free and available to all, but due to the center’s lack of funding and the restrictions set on the import of certain drugs, about a third of our patients are forced to buy their medication from local drug stores run by the clinic. Not everyone is able to procure their treatment, and the center isn’t able to treat everyone. We used to move more critical patients, like those suffering from leukemia or brain cancer, to Turkey for treatment, but that all halted with the coronavirus pandemic.”

Deteriorating Health Conditions

In the city of Ma'arrat Misrin north of Idlib, Ru’aa al-Ali, an 8-year-old brain tumor patient, hasn't been able to enter Turkish territories for treatment despite best efforts, as Turkey continues to cut-off access to its border passes with Syria due to the ongoing pandemic.

Her mother says Ru’aa was diagnosed a year ago and underwent a 3-month-long treatment in Turkey. She returned to rural Idlib after her condition stabilized, however, “her state has worsened recently and she needs radiotherapy, which is unavailable here.”

The distraught mother goes on to say, “The Turkish medical team refused to let her pass despite all our appeals, saying she is a non-emergency ‘cold case’... The delay in her treatment can lead to the growth and spread of the tumor, deteriorating her already worsening state.”

Turkish authorities in the border crossing could not be reached for comment, while the head of a Turkish-run medical center in rural Aleppo declined to comment on the halt of medical transfers regarding both cancer and chronic disease patients.

With the continued closure of the border pass amidst the ongoing pandemic and the number of those suffering from chronic illnesses continuing to grow, the fate of more than 400 cancer patients denied access to treatment, remains pending.

This investigation was carried out under the supervision of the ‘Syrian Investigative Reporting for Accountability Journalism‎ (SIRAJ)’ and the support of the ‘International Center for Journalists (ICFJ)’, as well as the Facebook Journalism Project.