NEW YORK – Since the start of the Syrian conflict in 2011, hundreds of medical personnel have been killed, ambulances have come under fire and pharmacies have been destroyed, creating a nationwide healthcare crisis. As a result, many of those injured in Syria’s continued violence cannot be treated, but another, often overlooked, consequence of the country’s deteriorating healthcare system is that millions of people suffering from chronic illnesses have been left without access to doctors and essential medication.

For Syrians living with chronic diseases such as diabetes, asthma, cancer and kidney and heart diseases – long-lasting conditions that can often be managed but not cured – living in war-torn Syria means not only coping with bombs and bullets, but also the additional burden of their unmanaged symptoms. Worsening health conditions in Syria have also allowed for the resurgence of life-threatening illnesses that had largely been eradicated. If not treated, many of these chronic illnesses can result in dangerous complications, and in some cases, death. Yet the lives lost to these diseases are often overshadowed by the devastating death toll from violence.

Last year, Medecins Sans Frontieres (MSF) reported that chronic illnesses were “killing just as many people as are bullets and bombs in Syria and in neighboring countries.” The Syrian American Medical Society, meanwhile, estimated in 2014 that at least 200,000 Syrians had already died since 2011 from chronic diseases such as cancer, asthma and diabetes. Yet the lives lost to these non-communicable but mostly treatable conditions are often overlooked amid the fighting.

Globally, chronic diseases are the leading causes of mortality, responsible for around 60 percent of all deaths worldwide. Cardiovascular diseases are the biggest killer, followed by cancer, respiratory disease and diabetes. Before the start of the conflict, Syria was a middle-income country with a functioning and comprehensive health system, burdened with its own share of chronic diseases, similar in magnitude to that of the United States – in 2010, heart disease accounted for 35 percent of all early deaths in the U.S., and 44 percent in Syria. Syria’s burden of chronic disease did not lift with the onset of war.

More than five years of war have left the country politically and territorially divided, and Syria’s healthcare system has also been fractured along those lines. Treatment and facilities are radically different in areas still controlled by the Syrian government than they are in opposition-held territory.

“In government controlled areas, there are specialized physicians and secure healthcare facilities … diagnostic services are also in place,” Dr. Bachir, a senior health program manager working with the Syrian American Medical Society Foundation (SAMS), an NGO focused on delivering medical care to Syrians, told Syria Deeply. “There is some kind of stability to manage these diseases and there are some medications available at local markets and at private pharmacies.”

Dr. Bachir, who asked that his full name not be used for security reasons, continued: “There is an acute lack of human resources, and the number of specialized physicians is very low. A lot of medical students are working as physicians, there is a lack of protocols, there is a lack of a safe environment to work. Many of the chronic disease patients need hospitalization but [hospitals] are highly targeted and dangerous places.”

Incessant attacks on hospitals and medical facilities in Syria have led to the loss of hundreds of lives, including more than 730 medical workers, according to Physicians for Human Rights. By the end of last year, at least 246 medical facilities in both opposition and government held areas had been hit in 346 separate attacks.

But those who do brave the danger of visiting a medical facility are often met with additional obstacles. Many life-saving medications for those suffering from a chronic illness are no longer available in northern Syria. Critical diagnostic services are also lacking. In Aleppo and Idlib, outside government control, just three CT scanners are available to serve 4 million to 5 million people. (The U.S. averages around 35 scanners per million people, according to the latest figures available from 2007.)

Medical supplies are routinely removed from aid convoys, on the infrequent occasions when requests to deliver assistance are approved by the Syrian authorities. In 2016, the World Health Organization submitted 21 requests to the Syrian government for permission to deliver medical supplies to 82 locations, according to the U.N. secretary-general’s May report to the Security Council. Only five requests had been approved. In April, 47,459 medical supplies were removed from convoys bound for Homs, Aleppo and Rif Dimashq. Surgical supplies, mental health medicines, burn kits, multivitamins, and antibacterial soap did not reach their destinations.

One of the most gaping holes is the lack of insulin, the main medication to treat type 1 diabetes, which mainly affects children, Bachir said. Roughly 60 percent of Syrians who are insulin-dependent are at risk due to lack of supplies, according to WHO. Before the conflict, Syria was home to some 200 clinics specialized in diabetes treatment and roughly one in 10 Syrians suffer from the disease, according to WHO.

Dialysis patients are among those who suffer most as a result of limited supplies, particularly as the complex treatment regimen for renal disease is hard to maintain in a hostile environment.

Aid agencies and independent NGOs have made only a small dent in treatment for those with renal disease. Although exact figures are lacking, the United Nations aimed to reach around 5,000 dialysis patients in 2013. The ICRC reports receiving around 100 dialysis patients each month in Homs in 2015.

#Talbiseh has lacked basic medical supplies for too long. Today we delivered wheelchairs & dialysis machines. #Syria pic.twitter.com/isfDlySKsu

— ICRC Syria (@ICRC_sy) April 27, 2016

In Aleppo, one of the hardest-hit cities in the war, only two dialysis clinics, serving some 40 patients, are still functioning, according to Dr. A. Oussama Rifai, a Syrian-American physician specializing in kidney disease and dialysis. However, even though the clinics have the necessary equipment, they often lack the steady supply of electricity, clean water and filters for blood filtration needed to operate the machines, as well as the oversight of a knowledgeable technician.

In 2013, Dr. Rifai established a network of experts within and outside Syria to provide real-time consultations and advice to medical personnel serving dialysis patients. Still, many patients have lost their lives because of lack of access to dialysis. In February, two people died in the besieged city of Douma in East Ghouta when lack of supplies suspended dialysis at the city’s clinic. Another 17 people with renal failure were also at risk.

Diabetes was on the rise in Syria before the war, but war conditions in the country have made this disease, and several others, increasingly rampant. Poor nutrition exacerbates the problems faced by people living with chronic disease and contributes to the growing public health crisis that has already seen the resurgence of polio, tuberculosis and leishmaniasis, a parasitic disease that can affect the skin and internal organs.

“Nothing works unless you are well nourished,” Sparrow said. “It’s absolutely fundamental whether you’ve got cancer or HIV or TB or cystic fibrosis, you have to be adequately nourished for any medication to work, for any vaccine to have uptake.”

Around a million people are living in 46 communities that are currently under siege with little access to food, clean water and medical supplies and around 80 percent of Syrians are living in poverty, according to Siege Watch. Siege conditions have become so dire that some are starving to death – 43 people in besieged Madaya died from starvation between September 2015 and March 2016.

Poor living conditions have also added to the overall burden of chronic illnesses people face in Syria, even when the illness itself is not life threatening.

“Chronic rheumatoid disease is probably one of the most prevalent diseases worldwide that affects your ability to just perform everyday functions: getting out of bed, having a shower, feeding yourself,” said Dr. Annie Sparrow, a pediatrician and assistant professor of global health at the Icahn School of Medicine at Mount Sinai, New York. “But if you can’t get access to the drugs to treat yourself, then that’s going to have a huge impact on your functionality day to day.”

The war’s impact on Syrians suffering from chronic illnesses also extends past Syria’s borders. Since the conflict began, more than 4 million people have left Syria, many crossing the border into neighboring Jordan. In May this year, MSF opened a new clinic in Jordan specializing in chronic disease care. The clinic is seeing around 500 new patients per month. “Some patients haven’t seen a doctor in two or three years,” said Khaled Ahmed, medical coordinator with MSF.

Diabetes and hypertension are among the most common conditions Ahmed has seen at the clinic. If these diseases go untreated, patients can experience the complication of diabetes, including problems in the coronary artery, with coronary diseases; and they have become more prone to infection and may have long term complications, he said.

But with so many other pressing needs for refugees – the high cost of living, providing food and other expenses – patients themselves neglect the disease, said Ahmed. For those who leave Syria and find medical care at facilities like the MSF Jordan clinic, managing their condition is far from easy.

“It’s challenging to treat chronic diseases under these conditions because chronic disease management involves managing the diet, the patient needs to exercise, they need to avoid stress,” Ahmed said. “When you look at the life of a refugee these things are very hard to get; they are already leading a stressful life, their ability to do exercise or have a balanced diet, that is not easy. It is very hard to get them to concentrate on how to take care of themselves.”