AMMAN: Every few weeks, Ahmad packs into a waiting room at Syria’s only cancer center.
While he waits for treatment at al-Bayrouni University Hospital in Damascus, the 27-year-old, who has stage 3 bone cancer, listens to his fellow patients as they discuss the medicine shortages.
“I overheard a patient saying the doctors gave him a low dosage, only enough to kill a fraction of the tumor, so the cancer had spread,” Ahmad, a Damascus native and father of two, told Syria Direct. “How am I supposed I feel after hearing stories like these?”
Ahmad was diagnosed with bone cancer one year ago, with his doctor citing a genetic pre-disposition for the disease.
“It began with extreme fatigue in my limbs, then abdominal pain,” he said. Ahmad’s doctor transferred him to the al-Bayrouni Hospital for immediate chemotherapy treatment due to the advanced progress of the cancer.
But the state-run medical center—located in the eastern Damascus suburbs on the border with rebel-held East Ghouta—cannot adequately treat all of its patients due to persistent shortages of cancer drugs, which began in 2011, a member of the medical staff and a hospital administrator told Syria Direct.
With Syria’s pharmaceutical industry in ruins after six years of war, American and European sanctions, which are supposed to allow the delivery of food and medicine, are in reality obstructing the importation of cancer drugs for Ahmad and patients like him.
Humanitarian exemptions embedded in the US- and EU-imposed restrictive measures should allow for the delivery of most pharmaceuticals to Syria—the exception being substances with alternate military uses. However, in practice, sanctions do impact the price and availability of cancer pharmaceuticals in Syria. Restrictive measures create a shortage of payment channels for imports by prohibiting transactions with Syria’s main financial institutions. At the same time, legal liability and steep penalties deter companies from exporting pharmaceuticals to Syria.
Al-Bayrouni University Hospital. Photo courtesy of Zaman al-Wasl.
In other words, it simply isn’t worth the risk to export cancer drugs to Syria. As a result, government-run public hospitals such as al-Bayrouni are unable to supply patients like Ahmad with sufficient, affordable cancer treatment drugs.
Each year, al-Bayrouni Hospital admits 13,000 new patients, an administrative director in the oncology department told Syria Direct, speaking on condition of anonymity. The impact of the sanctions and Syria’s wartime economy mean limited availability of medication and insufficient dosages for those patients as the humanitarian loopholes embedded in the sanctions fail to fulfill their purpose.
The United States first imposed sanctions on the Syrian Arab Republic in 2004 after claiming that the Syrian government was “supporting terrorism.” A series of presidential executive orders in 2011 and 2012 intensified the sanctions “in response to the ongoing violence and human rights abuses taking place in Syria.”
The EU followed suit in 2012, passing the first of several restrictive measures against the Syrian regime.
Justine Walker, director of financial crime, sanctions and bribery at the British Bankers’ Association, works with financial institutions and humanitarian organizations to identify effective channels for delivering aid to Syria in light of the sanctions.
Sanctions have “humanitarian carve-outs,” she told Syria Direct, explaining that there are “very clear” provisions for exporting medicine to Syria.
“It’s the practicalities of how that [delivery of food and medication] works in operation which become challenging, particularly when it involves a sanctioned entity,” she added.
The main obstacle lies in securing a payment channel for these exports. The restrictive measures on Syria extend to the nation’s main financial institutions, notably the Central Bank of Syria. Syrian ministries and public health institutions face a scarcity of non-sanctioned payment channels for importing medication.
Working around sanctions
The purchase and delivery of medicine becomes far more difficult when the processes “involve a government department or ministry which is caught by the sanctions,” Walker explained.
Even with a payment channel, financial transactions are still subject to lengthy delays for investigation and blockages.
In June 2013, Arnall Golden Gregory LLP, a US-based law firm that represents companies in the pharmaceuticals industry, issued a warning to its clients regarding US export controls and sanctions.
“Just because a product may be freely exported under the Export Administrations Regulation does not mean that the transaction is consistent with Office of Foreign Assets Control’s regulations (and vice-versa),” the statement read.
The Syrian Minister of Higher Education visits al-Bayrouni University Hospital. Photo courtesy of Syrian Ministry of Higher Education.
In other words, even though goods, such as food or medicine, are allowed to be exported to Syria, transactions necessary for the delivery of said goods could still breach US sanctions.
A criminal violation of US sanctions against Syria can incur a one million dollar fine and imprisonment. US sanctions legislation maintains “strict liability,” meaning that even inadvertent sanctions violations will incur a penalty. Penalties for breaching EU sanctions vary by country with violations incurring both fines and imprisonment.
One of main challenges for companies is carrying out all due diligence to ensure their products will arrive at their intended destinations, Walker told Syria Direct.
“Is the good going to ultimately be used in the way it is supposed to be, or will it be diverted to sanctioned actors and be used illegitimately?” she asked.
‘Before the war, medicine was abundant’
As a result of medication shortages, cancer patients like Ahmad are not able to get the consistent care they need. But that wasn’t always the case in Syria.
In 2010, Syria was on the cusp of pharmaceutical self-sufficiency with 90 percent of medicine locally produced, according to a 2010 overview of the Syrian pharmaceutical industry in the Journal of Medicine and Life, a periodical of global health issues published at Davila University of Medicine and Pharmacy in Romania.
Before the war, al-Bayrouni University Hospital, a public medical facility, provided patients medicine “free of charge,” Dr. Eyad Darwish, an oncology specialist and medical researcher at al-Bayrouni Hospital, told Syria Direct.
Now, the hospital cannot even offer treatment to all its cancer patients, let alone for free, said Darwish.
Since 2010, the majority of the factories that once produced medicine in the provinces of Aleppo, Homs and Outer Damascus have closed due to either damage during the war or insufficient materials, according to a 2013 press release by the World Health Organization.
The Aftermath of 2016 airstrike on Arak Pharma factory. Photo courtesy of Thiqa Agency.
The same WHO press release identified challenges faced by Syria’s medical sector, including “economic sanctions, difficulties in bank transactions, currency fluctuations, a decrease in the allocated budget for the Ministry of Health and the damage done to hospitals and medical facilities.”
In mid-October 2016, Russian airstrikes purportedly destroyed a western Aleppo countryside factory belonging to pharmaceutical company Arak Pharma, reported the UK-based Syrian Network for Human Rights at the time.
As Syria’s health sector deteriorates, patients at al-Bayrouni, in the eastern Damascus suburbs, face delayed treatment due to insufficient medication, lower dosages, and prohibitively high prices for medicine, according to Eyad Darwish, the administrative director in the hospital’s oncology department.
Ahmad, the bone cancer patient, purchases Lysodren, an anti-cancer medication, from smugglers who bring it from Lebanon. At $700 per weekly dose, Ahmad is supposed to take the medication when the hospital cannot provide him with chemotherapy treatment.
“It’s more than I can afford,” he told Syria Direct. “My relatives all donated money so I could purchase it because the pain was too much to take.”
With irregular chemotherapy sessions at the hospital and his inability to purchase the medicine, Ahmad says he regularly forgoes weekly treatment.
Despite the shortages faced by patients and their physicians, the Syrian Ministry of Health, which oversees al-Bayrouni Hospital along with the Ministry of Higher Education, refuses to acknowledge the negative impact of the sanctions.
In May 2015, Syrian Health Minister Dr. Nizar Yazigi claimed that Syria’s health sector was able to meet “89 percent of the national need…in spite the economic sanctions imposed on the Syrian people,” the Damascus-based Syria News reported at the time.
In reality, al-Bayrouni Hospital has less than half of the required cancer medicines, according to Darwish, whereas “before the war, medicine was abundant.”
The Syrian Essential Medicines List 2016, compiled by the WHO, contains dozens of cancer and chemotherapy drugs that state-run hospitals are lacking.
For its part, the World Health Organization has worked in conjunction with the Syrian Ministry of Health to provide medication to Syrians, distributing 45,000 treatments to cancer patients in Damascus and Latakia, according to the WHO 2015 annual report.
Syria as a ‘new customer’
As sanctions limit the flow of medicine to Syria, the government is looking for new sources for importing cancer drugs.
In October 2016, Dmitry Morozov, director of the Russian pharmaceutical company BIOCAD, announced that his company would supply Syria with a generic cancer medicine until the year 2021 after receiving authorization from the Syrian Ministry of Health, the Syria Times reported at the time.
When asked about the BIOCAD announcement, al-Bayrouni administrative director Darwish said he believes it will help the hospital’s cancer patients, but “the decision still needs time to come into effect.”
Syria is signing up as a “new customer” in the pharmaceutical industry, as Justine Walker of the British Bankers’ Association described it. After falling from near self-sufficiency to severe shortages, public-health organizations must now seek out pharmaceutical sources without the benefit of any pre-existing relationships.
Few incentives exist for pharmaceutical companies to export to Syria. Fear of violating sanctions law is the main deterrent preventing pharmaceutical companies from entering into agreements to provide medication to actors in Syria.
Justine Walker, commissioned by the UN as an independent sanctions expert, published the report “The Humanitarian Impact of Syria-Related Unilateral Restrictive Measures” in May 2016, documenting the impact of EU and US sanctions.
In the study, Walker warns of a “chilling effect” in which American and European banks are reluctant to provide humanitarian and financial services to Syria due to “fear of sanctions issues, such as fines for inadvertent technical violations.”
As the Syrian government attempts to procure medication for cancer patients in its state-run hospital, patients are worried that persistent medicine shortages mean their illness is a certain death sentence.
“It’s enough just to hear the sounds of bombs, the feeling like death could strike at any moment,” said Ahmad. “The cancer is spreading and I don’t want my time on this earth to end.”
“It’s like I’m about to die twice: once from the cancer and once from the state of this country.”