AMMAN: In Syria’s southern Daraa province, Abdulrahman Ahmed visits his neighborhood pharmacist, rather than the doctor, whenever he is feeling ill.

From treating migraines to sharp abdominal pains, the local pharmacies in the town of Inkhil serve as a one-stop medical point for residents looking to get both a diagnosis and a prescription at once, a commonplace practice throughout Syria that long pre-dates the war.

Today, however, the shelves in pharmacies across the Daraa countryside are largely empty. Over-the-counter essentials—painkillers, anti-inflammatory drugs and cold medicine—are available, but prescription drugs for chronic illnesses such as heart disease, high blood pressure and diabetes are not. A closed border with Jordan, along with the Assad regime’s multi-year blockade of the province, limit the flow of everything and everyone into opposition-controlled Daraa.

So when the ordinary pharmacies are empty, “we’re forced to go to the corner store to get our medicine,” Ahmed told Syria Direct.

These one-room, neighborhood grocery stores, dakakeen, line virtually every crowded street and back alley across the Daraa countryside. Where they once sold bread, rice and other household items before the war, today they moonlight as black-market pharmacies where customers can walk out with everything from insulin to the amphetamine Captagon.

In hard-to-reach areas of the Daraa countryside, Syrians are left with few options beyond unlicensed pharmacies to procure prescription drugs, exposing families to unintended medical risks from inexperienced and profit-driven smugglers-turned-pharmacists.

“Every single time, we’re afraid that the owners of these fake pharmacies are going to give us the wrong medicine,” said Ahmed.

Often staffed by untrained individuals without pharmacology degrees, these “fake pharmacies” openly distribute controlled substances to Syrians with or without proper prescriptions. Sometimes, the people running these stores “don’t even have a high school degree,” said Dr. Abu Abdullah, the director of Inkhil’s Syria Martyrs’ Hospital, the only hospital in town.

“There’s absolutely nothing that qualifies some people to work as pharmacists,” Abdullah added.

The result is a “significant spread” of emergency medical cases involving poisoning, addiction and drug overdose when fake pharmacies sell inaccurate prescriptions or give incorrect medical advice. With the rise of these counterfeit pharmacies three years ago, Dr. Abdullah said he has seen a major influx of patients suffering from everything from vomiting and diarrhea to far worse.

“People have died” after taking either the wrong drug or dosage, he added. “We don’t have the ability to monitor the patients [and the drugs they take] after they leave the hospital.”

In late December, two parents rushed their infant child into the emergency room in Inkhil’s hospital. The boy’s eyes were yellow-tinged; he suffered from jaundice. But on this evening, he was displaying worrying signs atypical to a jaundice diagnosis.

While the parents believed they were giving their son medicine for his disease, the attending physician learned that over the course of weeks, they had accidentally been giving their infant large doses of phenobarbital, a medication used to treat epilepsy. The drug—mistakenly provided by an untrained and unlicensed pharmacist—left the child in “horrible shape,” said Dr. Abdullah. Doctors declared the boy dead within hours of his arrival to the hospital.

Four medical professionals across Daraa province told Syria Direct that unlicensed pharmacies are the direct cause of a province-wide increase in drug overdoses.

“Children have died; the elderly have died,” Abu Mohammad, a licensed pharmacist in the Daraa countryside and graduate of the University of Damascus, told Syria Direct. “This is what happens when people are given the wrong medication.”

‘Fake pharmacies are everywhere’

In the northwest of Syria’s Daraa province, 25km east of the Golan Heights, Inkhil was one of the first towns to join the wave of revolutionary protests in 2011. When the revolution became a war, the town’s native population began to leave en masse. In recent years, thousands of internally displaced Syrians found shelter in Inkhil. Today, 20,000 residents remain in the town, approximately half of its pre-war population.

Daraa, the birthplace of the Syrian uprising, has been a base of opposition strength. Over time, the Assad regime carved a sphere of influence both throughout the northern countryside and within the eponymous provincial capital. Most notably, the regime maintains control over the M5 highway, the main artery that connects Daraa city and the outlying towns to the capital and the rest of the country.

With Outer Damascus to the north and Suwayda to the east—two mostly regime-controlled provinces—loyalist forces completely encircled Daraa by 2013, giving the Assad government a stranglehold over the flow of supplies into opposition territory. Access to essential goods such as fuel, baby formula and medication became increasingly difficult in 2016 after Jordan ordered the closure of its northern border following a suicide attack over the summer.

In turn, Daraa has become a smuggler’s marketplace, more than half a dozen local residents tell Syria Direct, particularly for prescription medication for chronic diseases.

A licensed west Daraa pharmacy, short on prescription medication. Photo courtesy of Mohammad al-Hourani.

Smugglers bring the medication from regime-controlled Suwayda province into Daraa either through back-road trafficking routes or by paying checkpoint guards a substantial bribe. While some smugglers elect to sell their contraband medication at highly marked-up prices directly to licensed pharmacies and hospitals across the province, others opt to open their own pharmacies and play the parts of both middleman and end retailer.

The smugglers who run these fake pharmacies “are usually attached in some capacity to a rebel brigade or affiliated with some other large group,” said Inkhil resident Aburrahman Ahmed. “They’ve got the means, they’ve got the capital, and they’re able to get the medicine.”

Throughout Daraa province, “fake pharmacies are everywhere,” Abu Mohammad, a Daraa pharmacist, told Syria Direct. “In a town of, let’s say, 40,000 people, you’re bound to find upwards of 50 of them.”

Unlicensed pharmacies are proliferating across the province with virtually no oversight, largely due to the absence of a strong civil society.

“We’ve submitted a number of complaints to the local council and the courts,” one doctor in the west Daraa countryside who requested anonymity told Syria Direct. “But neither party is yet to come to a decision.”

Sheikh Osmat al-Absi, who heads the Court of Justice in Daraa (Dar al-Adl fil-Houran), a judicial body covering opposition-held territories in the south Syrian province, said he has faced the problem of unregulated pharmacies “since the founding of the court” in 2014. Al-Absi’s main prosecutorial target, however, are not the small-shop, black-market distributors, but rather licensed pharmacies that sell drugs without prescriptions.

“We’ll take their licenses, close them down and punish them if we confirm that they’re selling prescription drugs” in such a way, al-Absi told Syria Direct. “As of right now, this is what concerns us.”

'We’ve got no other choice’

Despite the risks posed by fake pharmacies, large portions of Daraa’s population cautiously receive these black-market shops, which provide residents with otherwise inaccessible medication.

“Of course it’s our preferred choice to go to a licensed pharmacy, but when we can’t get what we need then we’ve got no other choice but to go to a fake pharmacy,” Mohammad, a resident of the east Daraa countryside, told Syria Direct. “ These fake pharmacies simply have more medication than a regular pharmacy.”

Syria Direct spoke with the owner of a fake pharmacy in Inkhil on the condition of anonymity. The unlicensed pharmacist, who worked as an assistant pharmacist for four years before the war, was quick to defend his wartime trade.

“Look at the terrible situation” in Daraa, he said. “So much medicine is simply unavailable, but here, I run this pharmacy so those who are sick can get what they so desperately need.”

Dr. Abdullah of the Syria Martyrs’ Hospital says he is unmoved by the unlicensed pharmacist’s argument.

“Fake pharmacies are a means of making money; there’s no other motive to open one up,” he told Syria Direct. “The owners of these shops aren’t thinking about morality or the potential harm they may cause to people; they’re traders, and they’re here to turn a profit.”

In the town of Jasem, 7km southwest of Inkhil, Dr. Ihab al-Jalam and his medical team at the local a-Radwan Hospital face a similar inflow of patients who have taken either the wrong drug or the incorrect dosage.

“Fake pharmacies are selling neurological and psychiatric medication like they’re drugs, not like they’re medicine,” he said. “These pharmacies don’t care about the law…and we’re the ones having to treat everyone once they get sick and come in to the hospital.”

When asked about the dangers of untrained individuals selling potentially lethal medication, the owner of the fake pharmacy said: “Any mistake that we make—if we ever give the wrong medication—it’s because the doctors didn’t write the prescription clearly enough.”

He declined to elaborate further.

Inkhil resident Abdulrahman Ahmed said he has seen “a number of cases of [drug] poisoning” in his town. The risks of unlicensed pharmacies are clear, he added.

“Sure, these fake pharmacies are illegitimate…but it’s far preferable to have this medicine than nothing at all.”