Differences in Diabetes Care Among Healthcare-Seeking Participants in Damascus and Homs, Syria: A Facility-Based Cross- Sectional Comparative Study

Living with diabetes means living with a constant need for care. It requires regular visits to a doctor, a steady supply of medicine to keep blood sugar levels safe, and simple tests to check how well the body is managing the condition over time. When a country is stable, these things are usually available, even if they are not perfect. But when a nation is torn apart by years of war, the systems that deliver this care often break down. Roads become dangerous, hospitals lose power, and the people who run them may have to flee. In these broken landscapes, the question becomes not just whether a person can get medicine, but whether the entire chain of support—from the pharmacy to the lab test—still exists. This is the reality for millions of people in Syria, where a long-running conflict has left the healthcare system in a state of deep uncertainty.

Researchers recently set out to understand exactly how this breakdown affects people with diabetes in two specific Syrian cities: Damascus and Homs. While both cities have suffered, they have experienced the war differently. Damascus has managed to keep many of its hospitals and clinics functioning, whereas Homs has faced more severe damage to its infrastructure and greater economic hardship. To find out what this difference means for patients, a team of scientists traveled to temporary clinics run by a humanitarian group called Atlantic Humanitarian Relief. They did not look at the general population, but rather at the people who were brave enough to walk through the doors of these clinics to seek help. By comparing the experiences of patients in the two cities, the researchers hoped to see if being closer to a clinic actually meant getting better care, or if other invisible barriers were holding people back.

The team spoke with 273 people who had been diagnosed with diabetes. They asked about their lives, their jobs, how far they had to travel to get to the clinic, and whether they could afford their medicine. They also looked at medical records to see if the patients had recent test results that measure long-term blood sugar control. The results revealed a surprising and troubling picture. In Homs, the patients were older and less likely to have jobs than those in Damascus. They also lived much closer to the clinics; more than one-third of the people in Homs could reach a medical facility in less than ten minutes, compared to only a small fraction of those in Damascus. On the surface, this suggested that people in Homs had better physical access to care.

However, the story changed when the researchers looked at what actually happened once the patients arrived. Despite being closer to the clinics and reporting that they could find oral diabetes pills more easily, the patients in Homs were far more likely to receive no medication at all. About nine out of every hundred people in Homs left the clinic without a prescription for insulin or pills, compared to just one out of every hundred in Damascus. This gap was not explained by a lack of supplies, since the patients in Homs said the medicines were available. Instead, the researchers suspect that the lack of jobs and the resulting poverty meant that even when medicine was on the shelf, many people simply could not afford to buy it. The data showed that in both cities, very few people could afford their care, but the financial strain seemed to hit the unemployed patients in Homs hardest, leaving them without treatment.

The situation was even more stark when looking at the tests that track how well diabetes is managed. A key test, which gives a score of how well blood sugar has been controlled over the last few months, was missing for more than half of all the patients studied. This was especially true in Homs, where nearly two-thirds of the patients had no recent test results on file. In Damascus, fewer than half were missing these records. This suggests that the ability to run these tests has been severely damaged in Homs, or that patients are not returning for follow-up visits. Among the few patients who did have test results, the numbers were high in both cities, indicating that blood sugar levels were not being kept under control. But the sheer number of missing records in Homs points to a deeper problem: a system where the tools to monitor health are simply not working for everyone.

The study suggests that in a war-torn environment, being physically close to a hospital does not guarantee good health outcomes. For the patients in Homs, the barriers were not the distance they had to walk, but the money they did not have and the medical tests that were unavailable. The researchers found that the older age of the patients in Homs, combined with high rates of unemployment, created a perfect storm where the need for care was greatest, but the ability to receive it was weakest. While the study cannot prove that one factor caused the other, the patterns are clear: the people in the more damaged city were less likely to get medicine and less likely to get tested, despite living closer to the aid workers.

This work highlights a critical gap in how we think about helping people during and after conflicts. It shows that simply setting up a clinic is not enough if the people who need it cannot afford the medicine inside, or if the lab equipment needed to check their health is broken. The findings suggest that rebuilding health systems in places like Syria will require more than just fixing buildings; it will need a focus on making sure medicines are affordable and that the capacity to test and monitor patients is restored. Until these pieces are in place, the people living in the hardest-hit areas will continue to face a silent crisis, where the path to a doctor is short, but the path to health remains blocked.