Empty shelves at Tartus pharmacies as war cripples Syria’s pharmaceutical industry

AMMAN: Every morning, Salma Wannous sets out from her home village in Syria’s coastal Tartus province and rides seven kilometers through the low-lying mountains to the provincial capital in search of medicine for her brother Ali.

Ali has severe schizophrenia and relies on fluphenazine, an antipsychotic, to cope with his hallucinations—living “nightmares,” as Salma describes them.

And yet, almost every afternoon for the past three months, she’s returned home empty-handed.

“Whenever I go inside a pharmacy, they tell me that they have nothing,” the 26-year-old tells Syria Direct. “Many sick people come to the pharmacies for medicine, only to hear the exact same response.”

Without his medicine, Ali hallucinates and “starts to hit himself,” forcing his family to use any means available to calm him. “One time we had to tie him down just so he wouldn’t injure himself,” Salma says. Other than that, “we aren’t able to do anything.”

Medical shortages are not new to Syria. Siege warfare and six years of violence have cut off civilians in opposition-held areas from essential medicines, equipment and life-saving treatments, including kidney dialysis and incubators for newborns.

Even in Salma and Ali’s home province of Tartus, a regime bastion relatively insulated from the war, residents are being hit hard by a severe medicine shortage as manufacturers underproduce and export to more lucrative foreign markets for profit, say two pharmaceutical insiders and half a dozen residents who spoke to Syria Direct.

 A pharmacy near Damascus in May, 2016. Photo courtesy of ABDULMONAM EASSA/AFP/Getty Images

As a result, people like Ali Wannous are at the mercy of severe illnesses without drugs that were once widely available.

Despite a handful of anti-regime protests at the beginning of the revolution and small demonstrations against government-enforced fuel hikes in more recent years, Tartus remains largely untouched by the war compared with neighboring provinces.

A thin ridge of mountains running the length of the Syria’s western coastline shields it from battles in Hama and northern Homs province, while its majority Alawite population has earned Tartus, as well as its northern neighbor, Latakia province, a reputation as pro-regime heartland.

A recent Ministry of Tourism advertisement, featuring jet skis and rows of sunbathers, beckons tourists to visit the “always beautiful” Mediterranean beach resorts in Tartus.

In contrast, former resort towns across the country now held by rebels, such as Madaya in mountainous Outer Damascus, have been besieged for years by Syrian regime forces. There, frontlines fortified by snipers and thousands of landmines prevent even the most basic medical supplies from entering, leaving residents to die of kidney failure and other preventable diseases.

Six years of war, however, mean that residents in regime-held areas are now feeling the effects of a crippled pharmaceutical industry, which is underproducing for the local market and, in many cases, selling what medicine is still in production at quadruple the pre-war price.

It wasn’t always this way. Just before the war, Syria was on the cusp of pharmaceutical self-sufficiency with 90 percent of the country’s medicine locally produced, according to a 2010 overview of the Syrian pharmaceutical industry in the Journal of Medicine and Life, a periodical of global heal this sues published at Davila University of Medicine and Pharmacy in Romania.

Syrian Ministry of Health statistics from the same year also painted an optimistic picture, with 91 percent of Syria’s medicine produced in local factories. This placed Syria far above its neighbors Jordan and Lebanon, according to a 2010 report by Amwal Invest, a Jordanian investment firm.

 The Tartus health directorate in 2014. Photo courtesy of the Tartus Health Directorate Media Office.

But the majority of the factories that once produced medicine in the provinces of Aleppo, Homs and Outer Damascus—where 90 percent of manufacturers were located before the war—have closed due to either damage or insufficient materials, the Syrian Economic Forum, a Turkey-based think tank, reported in a 2013 study.

Still, officials at the Syrian Ministry of Health are downplaying the scope of country’s growing pharmaceutical crisis.

There are 70 factories—the same number as existed in 2010, before the war— still “covering 89 percent of the local market’s needs,” Syrian Health Minister Nizar al-Yaziji told state news agency SANA in December 2016.

“Due to terrorist attacks against the factories, around 16 went out of service, and the rate of coverage fell to 70 percent,” al-Yaziji said at the time. It was unclear whether or not he was referring only to regime-held areas of Syria, where drugs and other medical equipment are more readily available than areas under opposition control. “But today, most are back in service and the rate of coverage has risen back to 89 percent of the local market’s needs.”

However, the reality is far worse, even in Tartus, residents tell Syria Direct.

Mufid Marouf suffers from type 1 diabetes and visits Tartus city’s state-run health directorate “every day” in search of insulin injections, “only for them to tell me that I can find the medicine I need in nearby government hospitals,” the 46-year-old says.

At the hospitals, “the majority of the responses I get are that the medicine hasn’t arrived yet or that they’re all out of what I need,” which also includes test strips to monitor his blood sugar.

“It’s gotten to the point that local medical labs haven’t even had blood test strips for a month.”

Insulin, listed as a “core” medicine in the most recent WHO Model List of Essential Medicines, was once locally produced in Syria and abundant throughout the country.

In 2014, however, Syria’s sole insulin producer, Asia Pharmaceutical Industries, was forced to shut down when clashes between the regime and opposition forces in the west Aleppo countryside damaged its factory. 

 A pharmacy in Damascus on September 17, 2013. Photo courtesy of ANWAR AMRO/AFP/Getty Images

Now, in addition to life-saving medications such as insulin, even basic, over-the-counter drugs are in desperately short supply—and the numbers are much lower than those published most recently by the Ministry of Health.

More than 65 percent of “basic medicines” were unavailable in Tartus province as of February 2016, Hussam a-Sheikh, president of the Tartus pharmacists union told pro-regime outlet al-Iqtisadi in February.

This includes at least 90 percent of drinkable and chewable medicines for children, according to a January report in the pro-government newspaper Al-Watan. 

One mother in Tartus province, Umm Sarah, can’t find diarrhea medicine for her toddler-aged daughter—and the search has left her exasperated. “Medicine is no less important than food and water,” she tells Syria Direct from her home in Tartus.

Manufactured crisis?

Domestic pharmaceutical companies are themselves a part of the problem, pharmaceutical insiders tell Syria Direct.

As Syria’s health sector deteriorates, pharmaceutical companies—those that still have working factories—are scrambling to compensate and meet their profit margins.

Manufacturers are raising prices locally, and rather than selling to Syrians, they are increasingly exporting to “neighboring Arab countries and to Asia” in order to stay afloat, says Marwan, a pharmaceutical marketing director based in Damascus.

Companies are “exporting an amount of the medicines [they produce] just so they can make a profit and remain open for business,” an employee at one pharmaceutical factory told Syria Direct. He asked that his name not be published out of fear of losing his job.

Pharmaceutical exports are not a new phenomenon—Syria has been exporting medications mostly to its Arab neighbors since before the war, according to the Observatory of Economic Complexity, an economic data project at MIT. But Tartus pharmacists, left with largely empty shelves and a five percent decrease in profits in recent months, point to Syrian pharmaceutical companies, whom they blame for focusing more on foreign than domestic markets.

Pharmaceutical manufacturers in regime-controlled territories are “deliberately” underproducing in order to pressure the Ministry of Health to raise prices, says one Tartus pharmacist, Rana, who declined to give her full name.

“Throughout the Syrian war, the prices haven’t risen enough to satisfy the medical companies, but [did increase enough] to become an additional burden for citizens,” she tells Syria Direct.

Some companies “are exporting their medicine in order to make a large profit—all at the expense of the local market.”

That means price hikes of up to 400 percent on medicines still available in the local market, according to recent news reports. The Syrian Ministry of Health in late February quadrupled the prices of locally produced drugs, including eltroxin, a thyroid medication, which increased from SP250 ($1) to SP1,000 ($4), pro-regime outlet al-Iqtisadi reported at the time.

Another basic medicine, mesalazine, an anti-inflammatory drug used in treating Crohn’s disease, rose from SP485 ($2.25) to SP2,160 ($10) per dose.

The price “adjustments” were meant to “cover the costs of bringing currently unavailable medicines back onto the market,” according to a Ministry of Health statement posted online in early March.

But for many people in Tartus, the new costs mean no medicine at all. One Tartus resident, who spoke to Syria Direct on condition of anonymity, says he can no longer afford his medication, even though “it is still just as important as bread.”

Salma Wannous, still determined to find her brother Ali’s schizophrenia medication despite recent price hikes, has started to visit Tartus hospitals instead of pharmacies, after repeatedly finding empty shelves. But even at state-run hospitals, she requests her brother’s fluphenazine “only to be told there is none.”

“This medicine cutoff is making my brother suffer,” she says, as his illness causes him to increasingly “forget his surroundings from one moment to the next.”

“Nobody knows how much longer this will go on.”